Augusta University Physician Web Directory Input Form

All fields that are marked with * must be completed.
Please send a digital photo in jpg format to marketing@augusta.edu.

First name *

Middle initial or Name

Suffix (Jr., III, etc.):

Last name *

Degree (MD, DDS, etc.): *

Administrative title:

Faculty rank:(Professor, Associate Professor, etc.)

E-mail address (will not be displayed on website) *

Affiliations: *

Georgia License #: *

NPI #:

Augusta University Health Staff ID #: *

Office Location #1

Practice name: *

Office address: *

Building:

City: *

State: *

Zip: *

Telephone: (Will not be displayed on web site.) *

Office Location #2

Practice name:

Office address:

Building:

City:

State:

Zip:

Telephone: (Will not be displayed on website)

Office Location #3

Practice name:

Office address:

Building:

City:

State:

Zip:

Telephone: (Will not be displayed on website)

Specialty (please select at least one)

Specialty #1: *

Certification: *

Board Certified? *

Specialty #2:

Certification:

Board Certified?

Specialty #3:

Certification:

Board Certified?

Languages Spoken

Main

#2:

#3:

Clinical Area of Interest

(2500 character limit)

Philosophy of Care

(2500 character limit)

Research Interest

(2500 character limit)

Education

(Please give complete name of school and year completed.)

Medical School: *

Internship:

Residency:

Fellowship:

Short Biography


(5000 character limit)

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