MEDICARE: ST. MARY'S MEDICAL GROUP, INC.

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1285116210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. MARY'S MEDICAL GROUP, INC.

Provider Business Mailing Address
First Line	:	PO BOX 48089
Second Line	:
City	:	ATHENS
State	:	GA
Zip	:	30604-8089
Country	:	US
Telephone Number	:	706-389-3740
Fax Number	:	706-389-3951

Provider Business Practice Location Address
First Line	:	2421 MALCOM BRIDGE RD STE 240
Second Line	:
City	:	BOGART
State	:	GA
Zip	:	30622-2325
Country	:	US
Telephone Number	:	706-208-8038
Fax Number	:	706-208-8039

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BRITTAINY HORNE
Credential	:
Telephone Number	:	706-389-3940

Provider Enumeration Date	:	09/06/2018
Last Update Date	:	08/21/2025

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