Healthcare Provider Details

I. General information

NPI: 1114984523
Provider Name (Legal Business Name): AUGUSTA UROLOGY SURGICENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 13TH STREET, SUITE 17
AUGUSTA GA
30901-2700
US

IV. Provider business mailing address

811 13TH STREET, SUITE 17
AUGUSTA GA
30901-2700
US

V. Phone/Fax

Practice location:
  • Phone: 706-724-4111
  • Fax: 706-823-0533
Mailing address:
  • Phone: 706-724-4111
  • Fax: 706-823-0533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number121-153
License Number StateGA

VIII. Authorized Official

Name: MS. LINDA G. FLOWERS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 706-724-4111