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General NPI Number Information
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NPI Number | 1982921771
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Entity Type | Organization
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Legal Business Name | SPORTS MEDICINE AND REHABILITATIVE THERAPY
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Dates
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Enumeration Date | 05/03/2010
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Last Update Date | 05/09/2011
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Provider Practice Location Address
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Address Line | 182 SUNSET BLVD
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City | JESUP
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State | GA
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Zip | 31545-0401
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Country | US
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Telephone | 912-385-2333
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Fax | 912-385-2350
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Provider Business Mailing Address
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Address Line | PO BOX 5048
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City | MACON
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State | GA
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Zip | 31208-5048
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Country | US
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Telephone | 912-385-2333
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Fax | 912-385-2350
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Authorized Official
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Title or Position | OWNER
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Name | DR. GREGORY WHITE
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Credential | MD
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Telephone | 912-385-2333
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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 | 26436
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License Number State | TN
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