Healthcare Provider Details

I. General information

NPI: 1457687964
Provider Name (Legal Business Name): MATTHEW S PUGLIESE, M. D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 10/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 SAINT SEBASTIAN WAY SUITE 7C
AUGUSTA GA
30901-2643
US

IV. Provider business mailing address

PO BOX 3346
AUGUSTA GA
30914-3346
US

V. Phone/Fax

Practice location:
  • Phone: 706-434-0130
  • Fax: 706-434-0131
Mailing address:
  • Phone: 706-434-0130
  • Fax: 706-434-0131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number062417
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number062417
License Number StateGA

VIII. Authorized Official

Name: DANA NELMS
Title or Position: PRACTICE MANAGER
Credential:
Phone: 706-434-0130