Healthcare Provider Details

I. General information

NPI: 1306826243
Provider Name (Legal Business Name): MANISH P GOVIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 WALTON WAY STE 5700
AUGUSTA GA
30901-5110
US

IV. Provider business mailing address

PO BOX 1524
AUGUSTA GA
30903-1524
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-7022
  • Fax: 706-774-7023
Mailing address:
  • Phone: 706-854-6008
  • Fax: 706-774-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number054214
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number54214
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: