Healthcare Provider Details

I. General information

NPI: 1104199751
Provider Name (Legal Business Name): UNIVERSITY MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2012
Last Update Date: 12/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 WEST AVE
NORTH AUGUSTA SC
29841-3800
US

IV. Provider business mailing address

PO BOX 1705
AUGUSTA GA
30903-1705
US

V. Phone/Fax

Practice location:
  • Phone: 803-279-1412
  • Fax: 706-774-7230
Mailing address:
  • Phone: 706-774-7263
  • Fax: 706-774-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: JULIE DEASON
Title or Position: DIRECTOR PHYSICIAN REVENUE CYCLE
Credential:
Phone: 706-774-8326