Healthcare Provider Details

I. General information

NPI: 1144593948
Provider Name (Legal Business Name): AUGUSTA PODIATRIC MEDICINE & SURGERY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 04/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MACTANLY PL SUITE A
STAUNTON VA
24401-2383
US

IV. Provider business mailing address

100-A MACTANLY PLACE
STAUNTON VA
24401
US

V. Phone/Fax

Practice location:
  • Phone: 540-886-6424
  • Fax: 540-213-0491
Mailing address:
  • Phone: 540-886-6424
  • Fax: 540-213-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103000705
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number0103000705
License Number StateVA

VIII. Authorized Official

Name: JOHN CCHELTREE JR.
Title or Position: SOLE OWNER
Credential: D.P.M.
Phone: 540-886-6424