Healthcare Provider Details

I. General information

NPI: 1043245939
Provider Name (Legal Business Name): STACY HAMMOND STORY III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 BLACKBURN DR
MARTINEZ GA
30907-8201
US

IV. Provider business mailing address

2231 CUMMING RD
AUGUSTA GA
30904-4335
US

V. Phone/Fax

Practice location:
  • Phone: 706-854-8340
  • Fax: 706-854-8388
Mailing address:
  • Phone: 706-829-3516
  • Fax: 706-733-8044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number017559
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number017559
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: