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General NPI Number Information
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NPI Number | 1154489383
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Entity Type | Organization
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Legal Business Name | ELBERTON SURGICAL LLC
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Dates
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Enumeration Date | 12/04/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 4 MEDICAL DRIVE 4TH FLOOR
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City | ELBERTON
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State | GA
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Zip | 30635-1830
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Country | US
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Telephone | 706-213-6618
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Fax | 706-283-6124
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Provider Business Mailing Address
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Address Line | 4 MEDICAL DR 4TH FLOOR
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City | ELBERTON
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State | GA
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Zip | 30635-1830
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Country | US
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Telephone | 706-213-6618
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Fax | 706-283-6124
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. WILLIAM KENDRIC HALEY
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Credential | M.D.
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Telephone | 706-213-6618
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 031754
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License Number State | GA
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