Provider Demographics
NPI:1922750462
Name:AUGUSTA UROLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:AUGUSTA UROLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-722-0705
Mailing Address - Street 1:4350 TOWNE CENTRE DR STE 2200
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3346
Mailing Address - Country:US
Mailing Address - Phone:706-722-0705
Mailing Address - Fax:
Practice Address - Street 1:4350 TOWNE CENTRE DR STE 2200
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3346
Practice Address - Country:US
Practice Address - Phone:706-722-0705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUGUSTA UROLOGY ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-26
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No1835X0200XPharmacy Service ProvidersPharmacistOncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300033214GMedicaid