Basic Information
| Provider Information | |||||||||
| NPI: | 1194762237 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATHENS-CLARKE EMERGENCY SPECIALISTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 48298 | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306048298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065433449 | ||||||||
| FaxNumber: | 7065435744 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 BAXTER ST | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 306063712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065433449 | ||||||||
| FaxNumber: | 7065435744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 11/15/2007 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7065433449 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | CG3792 | 01 | GA | RAILROAD MEDICARE | OTHER |