MEDICARE: ST. MARY'S MEDICAL GROUP, INC.

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	207RH0002X	Hospice and Palliative Medicine (Internal Medicine) Physician

General Provider Information

NPI Number	:	1932672300
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY'S MEDICAL GROUP, INC.

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

Provider Business Practice Location Address
First Line	:	1021 JAMESTOWN BLVD STE 215
Second Line	:
City	:	WATKINSVILLE
State	:	GA
Zip	:	30677-4176
Country	:	US
Telephone Number	:	706-389-2273
Fax Number	:	706-389-2298

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

Provider Enumeration Date	:	01/08/2019
Last Update Date	:	11/02/2022

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