Healthcare Provider Details

I. General information

NPI: 1124062112
Provider Name (Legal Business Name): 84PEDIATRIX MEDICAL GROUP UNIVERSITY HOSPITAL AUGUSTA GA.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WALTON WAY
AUGUSTA GA
30901-2629
US

IV. Provider business mailing address

4227 QUAIL SPRINGS CIR
MARTINEZ GA
30907-4610
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-8948
  • Fax:
Mailing address:
  • Phone: 706-863-4975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberRN042192
License Number StateGA

VIII. Authorized Official

Name: MRS. JOAN DANIEL HARPER
Title or Position: NEONATAL NURES PRACTITIONER
Credential: NNP
Phone: 706-774-8948