Provider Demographics
NPI:1063823482
Name:MACON MEDICAL CLINIC, LLC.
Entity Type:Organization
Organization Name:MACON MEDICAL CLINIC, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:MOHABUBUR
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-405-2121
Mailing Address - Street 1:3350 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2504
Mailing Address - Country:US
Mailing Address - Phone:478-405-2121
Mailing Address - Fax:478-405-0114
Practice Address - Street 1:3350 NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2504
Practice Address - Country:US
Practice Address - Phone:478-405-2121
Practice Address - Fax:478-405-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044065261QH0100X, 261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty