Provider Demographics
NPI:1366511834
Name:AUGUSTA UROLOGY ASSOCIATES, LLC
Entity type:Organization
Organization Name:AUGUSTA UROLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
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:706-312-3026
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:706-993-1284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300033214GMedicaid