Provider Demographics
NPI:1679626568
Name:SANDERSVILLE SURGICAL
Entity type:Organization
Organization Name:SANDERSVILLE SURGICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:K
Authorized Official - Last Name:RAWL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-553-0232
Mailing Address - Street 1:501 SPARTA RD STE C
Mailing Address - Street 2:
Mailing Address - City:SANDERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31082-1314
Mailing Address - Country:US
Mailing Address - Phone:478-553-0232
Mailing Address - Fax:478-553-1280
Practice Address - Street 1:501 SPARTA RD STE C
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1314
Practice Address - Country:US
Practice Address - Phone:478-553-0232
Practice Address - Fax:478-553-1280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054030208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GASECUREOtherRAW001
GAWELLCAREOther360483
GAWELLCAREOther360483
GAWELLCAREOther360483
I04339Medicare UPIN