=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255565503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPORTS MEDICINE ASSOCIATES OF AUGUSTA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2009
-----------------------------------------------------
Last Update Date | 04/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1706 MAGNOLIA WAY
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-9481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-210-7529
-----------------------------------------------------
Fax | 706-312-7608
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1706 MAGNOLIA WAY
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30909-9481
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-210-7529
-----------------------------------------------------
Fax | 706-312-7610
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. PATRICIA A. KINNEY
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 706-210-7529
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207XS0117X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery of the Spine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207XX0005X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Orthopaedic Surgery) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------