Healthcare Provider Details

I. General information

NPI: 1043351703
Provider Name (Legal Business Name): SPORTS MEDICINE ASSOCIATES OF AUGUSTA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 02/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 MAGNOLIA WAY
AUGUSTA GA
30909-9481
US

IV. Provider business mailing address

1706 MAGNOLIA WAY
AUGUSTA GA
30909-9481
US

V. Phone/Fax

Practice location:
  • Phone: 706-210-7529
  • Fax: 706-312-7610
Mailing address:
  • Phone: 706-210-7529
  • Fax: 706-312-7610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. PATRICIA A. KINNEY
Title or Position: ADMINISTRATOR
Credential: P.T.
Phone: 706-210-7529