Basic Information
| Provider Information | |||||||||
| NPI: | 1891957353 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHISENANT | ||||||||
| FirstName: | EBONY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 15TH ST STE BI1056 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309120004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067213813 | ||||||||
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| Practice Location | |||||||||
| Address1: | AUGUSTA UNIVERSITY MEDICAL CTR 1120 15TH STREET | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309122516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067218623 | ||||||||
| FaxNumber: | 7067211459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2008 | ||||||||
| LastUpdateDate: | 11/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME106882 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | TRN12292 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 83947 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 83947 | 01 | GA | GEORGIA MEDICAL LICENSE | OTHER |