1154787695 NPI number — GEORGIA REGENTS UNIVERSITY AUGUSTA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154787695 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:
Provider Other Organization Name Type Code:
6
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:
1154787695
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2016
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:
706-814-0111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 ALEXANDER DR
Provider Second Line Business Practice Location Address:
APT. 5222
Provider Business Practice Location Address City Name:
AUGUSTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30909-0243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-814-0111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BUCKLEY
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
DEAN
Authorized Official Telephone Number:
706-721-2273

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  008179 , 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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