Healthcare Provider Details

I. General information

NPI: 1528363066
Provider Name (Legal Business Name): COLUMBUS STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 UNIVERSITY AVE TUCKER HALL
COLUMBUS GA
31907-5679
US

IV. Provider business mailing address

PO BOX 671205
DALLAS TX
75267-1205
US

V. Phone/Fax

Practice location:
  • Phone: 706-507-8620
  • Fax: 706-568-2039
Mailing address:
  • Phone: 866-890-6390
  • Fax: 469-735-4640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: BECKY TEW
Title or Position: DIRECTOR, HEALTH SVC
Credential:
Phone: 706-507-8260