Southeastern OB/GYN Center LLC

Primary specialty

Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X

License

038019 Issued in GA

Legal business name

SOUTHEASTERN OB/GYN CENTER LLC

Practice address

5311 Paulsen St
Savannah, GA 31405-4800

Phone

(912) 355-1111

Fax

(912) 352-7136

NPI assigned

Jun 2, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Michael J Jackson, M.D.NPI 1730268046

Title

Owner

Phone

(912) 355-1111

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in GA

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Michael Joseph Jackson, MD

  • Obstetrics & Gynecology Physician
  • Savannah, GA
  • NPI 1730268046

  GA, Obstetrics & Gynecology

  Medicare reassignment NPD Authorized official
• Andrew Joseph Edwards III, MD

  • Obstetrics & Gynecology Physician
  • Savannah, GA
  • NPI 1710066097

  Obstetrics & Gynecology

  NPD (past)
• Angela Sinopoli Mock, CRN7A

  • Registered Nurse First Assistant
  • Savannah, GA
  • NPI 1932288834
  NPD (past)
• Carmela Amelia Pettigrew, MD

  • Obstetrics & Gynecology Physician
  • Savannah, GA
  • NPI 1295814432

  Obstetrics & Gynecology

  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1306972800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1678147200000",
    "number": "1346534831",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5311 PAULSEN ST",
            "city": "SAVANNAH",
            "state": "GA",
            "postal_code": "314054800",
            "telephone_number": "912-355-1111",
            "fax_number": "912-352-7136"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5311 PAULSEN ST",
            "city": "SAVANNAH",
            "state": "GA",
            "postal_code": "314054800",
            "telephone_number": "912-355-1111",
            "fax_number": "912-352-7136"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEASTERN OB/GYN CENTER LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-06-02",
        "last_updated": "2023-03-07",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "912-355-1111",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "M.D."
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Obstetrics & Gynecology",
            "state": "GA",
            "license": "038019",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00729473A",
            "state": "GA"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "038019",
            "state": "GA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• All providers in Savannah, GA
• Obstetrics & Gynecology Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 7, 2023; 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.

Verify at the official NPI Registry.