MEDICARE: AUGUSTA UROLOGY SURGICENTER, LLC

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
1	261QA1903X	Ambulatory Surgical Clinic/Center	121-153	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114984523
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUGUSTA UROLOGY SURGICENTER, LLC

Provider Business Mailing Address
First Line	:	811 13TH STREET, SUITE 17
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30901-2700
Country	:	US
Telephone Number	:	706-724-4111
Fax Number	:	706-823-0533

Provider Business Practice Location Address
First Line	:	811 13TH STREET, SUITE 17
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30901-2700
Country	:	US
Telephone Number	:	706-724-4111
Fax Number	:	706-823-0533

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MS. LINDA G. FLOWERS
Credential	:
Telephone Number	:	706-724-4111

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	01/11/2012

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