Healthcare Provider Details

I. General information

NPI: 1114200029
Provider Name (Legal Business Name): BENAISSA KADDOUR DJEBBAR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3405 MIKE PADGETT HWY EAST CENTRAL REGIONAL HOSPITAL -FORENSIC UNIT
AUGUSTA GA
30906-3815
US

IV. Provider business mailing address

2060 DUNDEE WAY
GROVETOWN GA
30813-8124
US

V. Phone/Fax

Practice location:
  • Phone: 706-792-7073
  • Fax:
Mailing address:
  • Phone: 706-627-3762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN 204732
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: