Basic Information
| Provider Information | |||||||||
| NPI: | 1922463132 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MACON GASTROENTEROLOGY ANESTHESIA ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 947351 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303947351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883373509 | ||||||||
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| Practice Location | |||||||||
| Address1: | 610 3RD ST | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312013294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4784642600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2015 | ||||||||
| LastUpdateDate: | 10/01/2021 | ||||||||
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| AuthorizedOfficialLastName: | KREGER | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2059994132 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.