1114124179 NPI number — MEDICAL MANAGEMENT CONCEPTS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114124179 NPI number — MEDICAL MANAGEMENT CONCEPTS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL MANAGEMENT CONCEPTS LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114124179
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5402 NEW FORSYTH RD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31210-0883
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-405-0454
Provider Business Mailing Address Fax Number:
478-405-7163

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 MOORES DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAHLONEGA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30533-0442
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-864-3136
Provider Business Practice Location Address Fax Number:
706-864-7479
Provider Enumeration Date:
07/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MARTIN
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
CHANCIE
Authorized Official Title or Position:
DIRECTOR OF FINANCE
Authorized Official Telephone Number:
478-405-0454

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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