Healthcare Provider Details

I. General information

NPI: 1154489383
Provider Name (Legal Business Name): ELBERTON SURGICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MEDICAL DRIVE 4TH FLOOR
ELBERTON GA
30635-1830
US

IV. Provider business mailing address

4 MEDICAL DR 4TH FLOOR
ELBERTON GA
30635-1830
US

V. Phone/Fax

Practice location:
  • Phone: 706-213-6618
  • Fax: 706-283-6124
Mailing address:
  • Phone: 706-213-6618
  • Fax: 706-283-6124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number031754
License Number StateGA

VIII. Authorized Official

Name: DR. WILLIAM KENDRIC HALEY
Title or Position: MANAGING MEMBER
Credential: M.D.
Phone: 706-213-6618