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
4750 WATERS AVE, SUITE 103, SAVANNAH, GA 31404-6200
(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
208600000X
Surgery Physician
—
—
2086X0206X
Surgical Oncology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
824884292A
—
GA
01
—
DO4195
RR MEDICARE
GA
Enumeration date
04/06/2009
Last updated
05/03/2011
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