Healthcare Provider Details

I. General information

NPI: 1013827567
Provider Name (Legal Business Name): MANTILLA SURGICAL COLORECTAL & PELVIC HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 MEDICAL CENTER DR STE 3
AUGUSTA GA
30909-6644
US

IV. Provider business mailing address

728 MICHAELS CRK
EVANS GA
30809-4042
US

V. Phone/Fax

Practice location:
  • Phone: 312-927-5299
  • Fax:
Mailing address:
  • Phone: 312-927-5299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: NATHALIE MANTILLA
Title or Position: PRESIDENT/CEO
Credential: MD, MPH
Phone: 312-927-5299