Provider Demographics
NPI:1053429688
Name:SOUTHEAST GEORGIA PRIMARY CARE
Entity type:Organization
Organization Name:SOUTHEAST GEORGIA PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:G
Authorized Official - Last Name:PROHASKA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:912-283-1359
Mailing Address - Street 1:409 UVALDA ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4574
Mailing Address - Country:US
Mailing Address - Phone:912-283-1359
Mailing Address - Fax:912-283-1362
Practice Address - Street 1:409 UVALDA ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4574
Practice Address - Country:US
Practice Address - Phone:912-283-1359
Practice Address - Fax:912-283-1362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3375Medicare ID - Type UnspecifiedGA MEDICARE GROUP NUMBER