Provider Demographics
NPI:1073589909
Name:EDDY, GARY SR (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:EDDY
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 PINE ST
Mailing Address - Street 2:STE 760
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2100
Mailing Address - Country:US
Mailing Address - Phone:478-633-6090
Mailing Address - Fax:478-633-2175
Practice Address - Street 1:840 PINE ST
Practice Address - Street 2:STE 760
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2100
Practice Address - Country:US
Practice Address - Phone:478-633-6090
Practice Address - Fax:478-633-2175
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050616207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000920598CMedicaid
GA000920598CMedicaid
GA16BBBPMMedicare ID - Type Unspecified