Provider Demographics
NPI:1265558118
Name:GEORGIA SOUTHERN UNIVERSITY
Entity type:Organization
Organization Name:GEORGIA SOUTHERN UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HEALTH SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-478-5641
Mailing Address - Street 1:PO BOX 5199
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79608-5199
Mailing Address - Country:US
Mailing Address - Phone:866-890-6390
Mailing Address - Fax:325-437-8390
Practice Address - Street 1:984 PLANT DRIVE
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30460-0001
Practice Address - Country:US
Practice Address - Phone:912-478-5641
Practice Address - Fax:912-478-1893
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA SOUTHERN UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-22
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty