Provider Demographics
NPI:1053380592
Name:OGEECHEE OB-GYN, P.C.
Entity type:Organization
Organization Name:OGEECHEE OB-GYN, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-871-6206
Mailing Address - Street 1:1497 FAIR RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0822
Mailing Address - Country:US
Mailing Address - Phone:912-871-6206
Mailing Address - Fax:912-681-8558
Practice Address - Street 1:1497 FAIR RD
Practice Address - Street 2:SUITE 300
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0822
Practice Address - Country:US
Practice Address - Phone:912-871-6206
Practice Address - Fax:912-681-8558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056210207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA056210OtherLICENSE
GA1053380592OtherNPI
GA16BBCSTMedicare ID - Type Unspecified
GA056210OtherLICENSE