Healthcare Provider Details

I. General information

NPI: 1013134816
Provider Name (Legal Business Name): JOSEPH SAM HADAWAY ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 RIVERSIDE PARK BLVD
MACON GA
31210-1395
US

IV. Provider business mailing address

120 OSIGIAN BLVD # B SUITE 100
WARNER ROBINS GA
31088-7880
US

V. Phone/Fax

Practice location:
  • Phone: 478-474-0240
  • Fax: 478-475-1340
Mailing address:
  • Phone: 478-953-5358
  • Fax: 478-953-5340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT001243
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: