Provider Demographics
NPI:1114570389
Name:BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA AND ON BEHALF....
Entity Type:Organization
Organization Name:BOARD OF REGENTS OF THE UNIVERSITY SYSTEM OF GEORGIA AND ON BEHALF....
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP FOR FINANCE AND ADMIN.
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:RACKLIFFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-413-3000
Mailing Address - Street 1:755 HANK AARON DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-1120
Mailing Address - Country:US
Mailing Address - Phone:404-413-4040
Mailing Address - Fax:404-413-4041
Practice Address - Street 1:755 HANK AARON DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-1120
Practice Address - Country:US
Practice Address - Phone:404-413-4040
Practice Address - Fax:404-413-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty