Basic Information
| Provider Information | |||||||||
| NPI: | 1104911049 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAYLOR | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1499 WALTON WAY | ||||||||
| Address2: | STE 1400 | ||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309012650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067246100 | ||||||||
| FaxNumber: | 7067225187 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 15TH STREET | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067214951 | ||||||||
| FaxNumber: | 7067217941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 003109 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0056PA | 05 | SC | MEDICAID | 1000002361A | 05 | GA | MEDICAID |