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General NPI Number Information
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NPI Number | 1003841511
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Entity Type | Organization
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Legal Business Name | AUGUSTA AESTHETIC SURGERY
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Dates
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Enumeration Date | 07/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2258 WRIGHTSBORO ROAD SUITE 180
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City | AUGUSTA
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State | GA
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Zip | 30904
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Country | US
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Telephone | 706-737-8827
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Fax | 706-737-8916
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Provider Business Mailing Address
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Address Line | 2258 WRIGHTSBORO ROAD SUITE 180
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City | AUGUSTA
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State | GA
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Zip | 30904
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Country | US
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Telephone | 706-737-8827
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Fax | 706-737-8916
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Authorized Official
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Title or Position | OWNER
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Name | MR. GARY BENTON WILLIAMSON
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Credential | MD
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Telephone | 706-737-8827
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 121224
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License Number State | GA
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