Healthcare Provider Details

I. General information

NPI: 1174691737
Provider Name (Legal Business Name): PETER J SKIDMORE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 01/31/2021
Certification Date: 01/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 15TH ST
AUGUSTA GA
30901-2608
US

IV. Provider business mailing address

950 15TH ST
AUGUSTA GA
30901-2608
US

V. Phone/Fax

Practice location:
  • Phone: 706-733-0188
  • Fax:
Mailing address:
  • Phone: 706-733-0188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number040789
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: