Healthcare Provider Details

I. General information

NPI: 1154381861
Provider Name (Legal Business Name): GEORGE JERYL EVERIDGE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 05/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 MANCHESTER EXPY STE A002
COLUMBUS GA
31904-6805
US

IV. Provider business mailing address

PO BOX 8983
COLUMBUS GA
31908-8983
US

V. Phone/Fax

Practice location:
  • Phone: 706-324-0081
  • Fax: 706-324-1965
Mailing address:
  • Phone: 706-324-0081
  • Fax: 706-324-1965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number14906
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number014906
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: