Healthcare Provider Details

I. General information

NPI: 1427354810
Provider Name (Legal Business Name): JONATHAN TRENT MAGRUDER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 05/24/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 KING AVENUE SUITE 230
ATHENS GA
30606
US

IV. Provider business mailing address

242 KING AVENUE SUITE 230
ATHENS GA
30606
US

V. Phone/Fax

Practice location:
  • Phone: 706-475-1700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberD77372
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMT218334
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number88653
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: