Basic Information
| Provider Information | |||||||||
| NPI: | 1457687964 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MATTHEW S PUGLIESE, M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3346 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309143346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064340130 | ||||||||
| FaxNumber: | 7064340131 | ||||||||
| Practice Location | |||||||||
| Address1: | 820 SAINT SEBASTIAN WAY | ||||||||
| Address2: | SUITE 7C | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7064340130 | ||||||||
| FaxNumber: | 7064340131 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2009 | ||||||||
| LastUpdateDate: | 10/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | NELMS | ||||||||
| AuthorizedOfficialFirstName: | DANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7064340130 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 062417 | GA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086X0206X | 062417 | GA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 143386616A | 05 | GA | MEDICAID |