Healthcare Provider Details

I. General information

NPI: 1609078047
Provider Name (Legal Business Name): MEDICAL COLLEGE OF GEORGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST # BAA-5407
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST # BAA-5407
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-2505
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number4804
License Number StateGA

VIII. Authorized Official

Name: STEPHANIE FARROW
Title or Position: PA-C
Credential: PA-C
Phone: 706-721-2505