Healthcare Provider Details

I. General information

NPI: 1275593790
Provider Name (Legal Business Name): AUGUSTA PEDIATRIC ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 AUGUSTA WEST PKWY
AUGUSTA GA
30909-1807
US

IV. Provider business mailing address

1245 AUGUSTA WEST PKWY
AUGUSTA GA
30909-1807
US

V. Phone/Fax

Practice location:
  • Phone: 706-868-0389
  • Fax: 706-651-0729
Mailing address:
  • Phone: 706-868-0389
  • Fax: 706-651-0729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JERRY MILLER JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 706-868-0389