1043528268 NPI number — MEDCARE PHYSICIANS OF CENTRAL GEORGIA, 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 1043528268 NPI number — MEDCARE PHYSICIANS OF CENTRAL GEORGIA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDCARE PHYSICIANS OF CENTRAL GEORGIA, 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:
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:
1043528268
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4867
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31208-4867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-453-2522
Provider Business Mailing Address Fax Number:
706-453-2523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1040 FOUNDERS ROW
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
GREENSBORO
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30642-5261
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-453-2522
Provider Business Practice Location Address Fax Number:
706-453-2523
Provider Enumeration Date:
09/22/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTSON
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
336-553-3322

Provider Taxonomy Codes

  • Taxonomy code: 208M00000X , 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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