Organization
PROVIDENT HEALTH SURGICAL ASSOCIATES, INC.
Active
Organization
PROVIDENT HEALTH SURGICAL ASSOCIATES, INC.
Active
Other names
ACI Surgical Associates
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. ROBIN J. MADDOX (PROVIDER ENROLLMENT COORDINATOR)
(912) 350-9335
Entity
Organization
Contact information
Practice address
4700 WATERS AVE, SAVANNAH, GA 31404-6220
(912) 350-2299
(912) 350-2298
Mailing address
PO BOX 102019, ATLANTA, GA 30368-2019
(912) 350-2299
(912) 350-2298
Taxonomy
Speciality
Code
Description
License number
State
207VX0201X
Gynecologic Oncology Physician
—
—
207Y00000X
Otolaryngology Physician
—
—
2086S0102X
Surgical Critical Care Physician
—
—
2086X0206X
Surgical Oncology Physician
Primary
—
—
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
824884292A
—
GA
01
—
DO4195
RR MEDICARE
GA
01
—
DO4198
RR MEDICARE
SC
05
—
GPA978
—
SC
Enumeration date
09/03/2008
Last updated
05/03/2011
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