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Organization
SOUTHEAST GA PRIMARY PREVENT
Active
Organization
SOUTHEAST GA PRIMARY PREVENT
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISA W. BUSH (BILLING MANAGER)
(912) 537-9779
Entity
Organization
Contact information
Practice address
1811 EDWINA DR, VIDALIA, GA 30474-8963
(912) 537-9779
(912) 537-2124
Mailing address
1811 EDWINA DR, VIDALIA, GA 30474-8963
(912) 537-9779
(912) 537-2124
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
052930
GA
Other
Enumeration date
07/20/2007
Last updated
05/08/2008
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