MEDICARE: DR. MARY JO GOOLSBY NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	RN060379 NP	GA

General Provider Information

NPI Number	:	1811993926
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY JO GOOLSBY NP

Provider Business Mailing Address
First Line	:	3421 WALTON WAY
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-4532
Country	:	US
Telephone Number	:	706-729-0832
Fax Number	:	706-774-8187

Provider Business Practice Location Address
First Line	:	1350 WALTON WAY
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30901-2612
Country	:	US
Telephone Number	:	706-774-8187
Fax Number	:	706-774-5020

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	07/08/2007

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