Healthcare Provider Details

I. General information

NPI: 1699029603
Provider Name (Legal Business Name): BRAD HEADLEY MD FACS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 10/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 VICTORY DR # A
SWAINSBORO GA
30401-3235
US

IV. Provider business mailing address

PO BOX 568
SWAINSBORO GA
30401-0568
US

V. Phone/Fax

Practice location:
  • Phone: 478-237-3291
  • Fax: 478-237-4344
Mailing address:
  • Phone: 478-237-3291
  • Fax: 478-237-4344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number039125
License Number StateGA

VIII. Authorized Official

Name: DR. WILLIAM B HEADLEY
Title or Position: GENERAL SURGERY
Credential: M.D.
Phone: 478-237-3291