Provider Demographics
NPI:1891069290
Name:ST. MARY'S MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ST. MARY'S MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:D. MONTEZ
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-389-3930
Mailing Address - Street 1:1000 COWLES CLINC WAY
Mailing Address - Street 2:SUITE D-300
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-5285
Mailing Address - Country:US
Mailing Address - Phone:762-243-3860
Mailing Address - Fax:762-243-3879
Practice Address - Street 1:1000 COWLES CLINC WAY
Practice Address - Street 2:SUITE D-300
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-5285
Practice Address - Country:US
Practice Address - Phone:762-243-3860
Practice Address - Fax:762-243-3879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA63440207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty