Provider Demographics
NPI:1548676026
Name:GEORGIA REGENT UNIVERSITY
Entity type:Organization
Organization Name:GEORGIA REGENT UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MEDEARIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:720-236-6258
Mailing Address - Street 1:518 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-7815
Mailing Address - Country:US
Mailing Address - Phone:720-236-6258
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:BIW-2144
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-2700
Practice Address - Country:US
Practice Address - Phone:706-721-3871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital