Active NPI
Statesboro Medical Group, LLC
- Urgent Care Clinic/Center
- Statesboro, GA
National Provider Identifier
1013535657
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Urgent Care Clinic/Center
- Legal business name
- STATESBORO MEDICAL GROUP, LLC
- Practice address
- 1176 Brampton Ave
Statesboro, GA 30458-0847 - Phone
- (912) 259-9474
- NPI assigned
- Jul 9, 2020
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Dr. Sreevalli Dega, MD
- Title
- Owner
- Phone
- (912) 259-9474
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Urgent Care Clinic/Center | 261QU0200X | Primary |
Addresses
Primary practice location
1176 Brampton Ave
Statesboro, GA 30458-0847
Mailing address
106 Irongate PL
Statesboro, GA 30458-9173
Phone (912) 531-7338
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1023247723 | Other | GA | NPI |
| 1023247731 | Other | GA | NPI |
Other names 1
- Statesboro urgent care
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in GA
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20201002000508 | GA | Part B Supplier - Clinic/Group Practice | 6507285095 |
Receives reassigned benefits from 9 practitioners Practice locations: Statesboro, GA |
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 11D2193606 | Statesboro Urgent Care | Certificate of waiver | Dec 31, 2027 |
National Provider Directory
National Provider DirectoryLocations
485 Jimmy Deloach Pkwy
Unit D
Savannah, GA 31407
1176 Brampton Ave
Statesboro, GA 30458
Phone (912) 259-9474
Practitioners & affiliated clinicians
Practitioners 9
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1594252800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1599782400000",
"number": "1013535657",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "106 IRONGATE PL",
"city": "STATESBORO",
"state": "GA",
"postal_code": "304589173",
"telephone_number": "912-531-7338"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1176 BRAMPTON AVE",
"city": "STATESBORO",
"state": "GA",
"postal_code": "304580847",
"telephone_number": "912-259-9474"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "STATESBORO MEDICAL GROUP, LLC",
"organizational_subpart": "NO",
"enumeration_date": "2020-07-09",
"last_updated": "2020-09-11",
"certification_date": "2020-09-11",
"status": "A",
"authorized_official_last_name": "DEGA",
"authorized_official_first_name": "SREEVALLI",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "912-259-9474",
"authorized_official_name_prefix": "Dr.",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "261QU0200X",
"taxonomy_group": "",
"desc": "Clinic/Center, Urgent Care",
"state": null,
"license": null,
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NPI",
"identifier": "1023247723",
"state": "GA"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NPI",
"identifier": "1023247731",
"state": "GA"
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "Statesboro urgent care",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "Statesboro urgent care",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Statesboro, GA
- Statesboro Gi Anesthesia LLC
- Statesboro Hma Medical Group, LLC
- Statesboro Hma Physician Management LLC
- Statesboro Imaging Center, P.C.
- Statesboro Imaging Center, P.C.
- Statesboro Neurosurgery, LLC
- Statesboro OB-GYN Specialists, PC
- Statesboro Oncology Assoc.
- Statesboro Opco LLC
- Statesboro Oral and Maxillofacial Surgery, Inc.
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 11, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.