Basic Information
| Provider Information | |||||||||
| NPI: | 1154758001 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEORGIA COLLEGE & STATE UNIVERSITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | GCSU SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 120 W CAMPUS DR CBX 091 | ||||||||
| Address2: | |||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310611990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784455288 | ||||||||
| FaxNumber: | 4784453142 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 W CAMPUS DR CBX 091 | ||||||||
| Address2: | |||||||||
| City: | MILLEDGEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310611990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784455288 | ||||||||
| FaxNumber: | 4784453142 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2013 | ||||||||
| LastUpdateDate: | 10/08/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF ADMINISTRATION & OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 4784455148 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Student Health |
No ID Information.