Healthcare Provider Details

I. General information

NPI: 1013927946
Provider Name (Legal Business Name): MELISSA JADICK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 DANTIGNAC ST SUITE 2600
AUGUSTA GA
30901-2775
US

IV. Provider business mailing address

1303 DANTIGNAC ST SUITE 2600
AUGUSTA GA
30901-2775
US

V. Phone/Fax

Practice location:
  • Phone: 706-854-2500
  • Fax: 706-774-7209
Mailing address:
  • Phone: 706-854-2500
  • Fax: 706-774-7209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number056877
License Number StateGA

VIII. Authorized Official

Name: CHRISTINA RIOS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 706-854-2558