Healthcare Provider Details

I. General information

NPI: 1114900123
Provider Name (Legal Business Name): MICHAEL SWANHART
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 EAST HOSPITAL ROAD DWIGHT D EISENHOWSER AMC
AUGUSTA GA
30909
US

IV. Provider business mailing address

2761 HUNTCLIFFE DR
AUGUSTA GA
30909-0662
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-1197
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number63823
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: