Healthcare Provider Details

I. General information

NPI: 1063738722
Provider Name (Legal Business Name): BERNADETTE T SKRUCK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 WALTON WAY STE 5700
AUGUSTA GA
30901-5110
US

IV. Provider business mailing address

2405 PERSIMMON RD
AUGUSTA GA
30904-3354
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-8242
  • Fax: 706-722-8351
Mailing address:
  • Phone: 312-927-6634
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number6394
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: