Provider Demographics
NPI:1053817676
Name:PHYSICIAN CONSULTANTS OF GEORGIA DUBLIN
Entity Type:Organization
Organization Name:PHYSICIAN CONSULTANTS OF GEORGIA DUBLIN
Other - Org Name:DUBLIN VASCULAR CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REUBEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-353-3044
Mailing Address - Street 1:PO BOX 13654
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-3654
Mailing Address - Country:US
Mailing Address - Phone:478-353-3044
Mailing Address - Fax:
Practice Address - Street 1:207 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2903
Practice Address - Country:US
Practice Address - Phone:478-353-3044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55819207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA180550000053643Medicaid