Provider Demographics
NPI:1043351703
Name:SPORTS MEDICINE ASSOCIATES OF AUGUSTA, LLC
Entity Type:Organization
Organization Name:SPORTS MEDICINE ASSOCIATES OF AUGUSTA, LLC
Other - Org Name:CHAMPION ORTHOPEDICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:KINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:706-210-7529
Mailing Address - Street 1:1706 MAGNOLIA WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-9481
Mailing Address - Country:US
Mailing Address - Phone:706-210-7529
Mailing Address - Fax:706-312-7610
Practice Address - Street 1:1706 MAGNOLIA WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-9481
Practice Address - Country:US
Practice Address - Phone:706-210-7529
Practice Address - Fax:706-312-7610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2015-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300034841AMedicaid
SCCJ3550OtherRAILROAD MEDICARE
GA30003484LAMedicaid
SCGPA745Medicaid
GA30003484LAMedicaid
SCCJ3550OtherRAILROAD MEDICARE