Healthcare Provider Details

I. General information

NPI: 1982921771
Provider Name (Legal Business Name): SPORTS MEDICINE AND REHABILITATIVE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 SUNSET BLVD
JESUP GA
31545-0401
US

IV. Provider business mailing address

PO BOX 5048
MACON GA
31208-5048
US

V. Phone/Fax

Practice location:
  • Phone: 912-385-2333
  • Fax: 912-385-2350
Mailing address:
  • Phone: 912-385-2333
  • Fax: 912-385-2350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number26436
License Number StateTN

VIII. Authorized Official

Name: DR. GREGORY WHITE
Title or Position: OWNER
Credential: MD
Phone: 912-385-2333