Organization
VIDALIA UROLOGY ASSOCIATES, LLC
Active
Parent organization
SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Organization subpart
Yes
Provider details
NPI number
Legal business name
SOUTHEAST REGIONAL PRIMARY CARE CORPORATION
Authorized official
TONY M OSTEEN (CFO)
(912) 538-5314
Entity
Organization
Contact information
Practice address
1707 MEADOWS LN STE F, VIDALIA, GA 30474-7201
(912) 537-9481
Mailing address
PO BOX 407, VIDALIA, GA 30475-0407
(912) 537-9481
(912) 537-1380
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
511G700994
MEDICARE
GA
Enumeration date
07/31/2008
Last updated
07/10/2020
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