Healthcare Provider Details

I. General information

NPI: 1457389504
Provider Name (Legal Business Name): AUGUSTA ORTHOPEDIC & SPORTS MEDICINE SPECIALISTS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 J DEWEY GRAY CIR
AUGUSTA GA
30909-1867
US

IV. Provider business mailing address

3650 J DEWEY GRAY CIR P O BOX 14039
AUGUSTA GA
30909-1867
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-9797
  • Fax: 706-860-7686
Mailing address:
  • Phone: 706-863-9797
  • Fax: 706-860-7686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ELLEN T COLLEGE
Title or Position: OFFICE ADMINISTRATOR
Credential: RT
Phone: 706-863-9797