Healthcare Provider Details

I. General information

NPI: 1124119219
Provider Name (Legal Business Name): COURAGE A ATEKHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 BERMUDA RUN
STATESBORO GA
30458-0858
US

IV. Provider business mailing address

1030 BERMUDA RUN
STATESBORO GA
30458-0858
US

V. Phone/Fax

Practice location:
  • Phone: 912-764-8396
  • Fax: 912-764-7188
Mailing address:
  • Phone: 912-764-8396
  • Fax: 912-764-7188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number049266
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2472R0900X
TaxonomyRenal Dialysis Technician
License Number049266
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: