Healthcare Provider Details

I. General information

NPI: 1083785349
Provider Name (Legal Business Name): SOUTHERN FAMILY MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 12/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3736 MIKE PADGETT HWY STE A
AUGUSTA GA
30906-0720
US

IV. Provider business mailing address

3736 MIKE PADGETT HWY STE A
AUGUSTA GA
30906-0720
US

V. Phone/Fax

Practice location:
  • Phone: 706-560-2273
  • Fax: 706-560-0903
Mailing address:
  • Phone: 706-560-2273
  • Fax: 706-560-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MIKE HODNICK
Title or Position: PRACTICE MANAGER
Credential:
Phone: 706-560-2273