1356709935 NPI number — GEORGIA REGENTS UNIVERSITY AUGUSTA

Table of content: (NPI 1356709935)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356709935 NPI number — GEORGIA REGENTS UNIVERSITY AUGUSTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GEORGIA REGENTS UNIVERSITY AUGUSTA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDICAL COLLEGE OF GEORGIA
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356709935
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1040 ALEXANDER DR
Provider Second Line Business Mailing Address:
APT 5222
Provider Business Mailing Address City Name:
AUGUSTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30909-0243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-288-6835
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1120 15TH ST
Provider Second Line Business Practice Location Address:
SUITE BP 4109
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30912-0004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-721-6100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/10/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BUCKLEY
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
DEAN, MEDICAL COLLEGE OF GEORGIA
Authorized Official Telephone Number:
706-721-2231

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  008180 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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