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NPI Code Detail

MEDICARE: BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA AND ON BEHALF....

MEDICARE: BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA AND ON BEHALF....
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207QS0010XSports Medicine (Family Medicine) Physician

General Provider Information

NPI Number : 1114570389
Entity Type Code : Organization
Provider Name (Legal Business Name) : BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA AND ON BEHALF....
Provider Business Mailing Address
First Line : 755 HANK AARON DR SW
Second Line :
City : ATLANTA
State : GA
Zip : 30315-1120
Country : US
Telephone Number : 404-413-4040
Fax Number : 404-413-4041
Provider Business Practice Location Address
First Line : 755 HANK AARON DR SW
Second Line :
City : ATLANTA
State : GA
Zip : 30315-1120
Country : US
Telephone Number : 404-413-4040
Fax Number : 404-413-4041
Authorized Official
Title or Position : SENIOR VP FOR FINANCE AND ADMIN.
Name : JERRY RACKLIFFE
Credential :
Telephone Number : 404-413-3000
Provider Enumeration Date : 07/17/2019
Last Update Date : 07/17/2019

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Directions to “BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA AND ON BEHALF.... ” Practice Location

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