Healthcare Provider Details

I. General information

NPI: 1982061677
Provider Name (Legal Business Name): ROBERT SCOTT MEDEARIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 01/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH STREET, BIW 2144
AUGUSTA GA
30912
US

IV. Provider business mailing address

1824 WALTON WAY
AUGUSTA GA
30904-3804
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-4544
  • Fax: 706-446-0077
Mailing address:
  • Phone: 706-737-9250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number80214
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number6924
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: