Provider Demographics
NPI:1568543551
Name:MEDICAL COLLEGE OF GEORGIA
Entity Type:Organization
Organization Name:MEDICAL COLLEGE OF GEORGIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF, PEDIATRIC ORTHOPAEDICS
Authorized Official - Prefix:MR
Authorized Official - First Name:STYLES
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERTRAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-721-2849
Mailing Address - Street 1:1120 15TH ST
Mailing Address - Street 2:BP-2109
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912-0004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:BP-2109
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-2849
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025718174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00312485AMedicaid
SCG25718Medicaid
SCG25718Medicaid
GAB92317Medicare UPIN