MEDICARE: WILLIAM LESLIE HORNBACK III MD

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	207X00000X	Orthopaedic Surgery Physician	20741	GA

General Provider Information

NPI Number	:	1316964208
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLIAM LESLIE HORNBACK III MD

Provider Business Mailing Address
First Line	:	1622 MADISON AVENUE
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31794-1228
Country	:	US
Telephone Number	:	229-388-5625
Fax Number	:	229-353-6377

Provider Business Practice Location Address
First Line	:	1622 MADISON AVENUE
Second Line	:
City	:	TIFTON
State	:	GA
Zip	:	31794-1228
Country	:	US
Telephone Number	:	229-388-5625
Fax Number	:	229-353-6377

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	06/18/2015

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