1497105597 NPI number — ST. MARY'S MEDICAL GROUP, INC.

Table of content: (NPI 1497105597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497105597 NPI number — ST. MARY'S MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ST. MARY'S MEDICAL GROUP, INC.
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:
1497105597
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 48089
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATHENS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30604-8089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-389-3740
Provider Business Mailing Address Fax Number:
706-389-3951

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
355 CLEAR CREEK PKWY STE 1003
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAVONIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30553-4271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-356-1422
Provider Business Practice Location Address Fax Number:
706-356-1425
Provider Enumeration Date:
06/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
HORNE
Authorized Official First Name:
BRITTAINY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
706-389-3940

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com