Provider Demographics
NPI:1073629630
Name:MACON GYN/OB ASSOCIATES
Entity Type:Organization
Organization Name:MACON GYN/OB ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:A
Authorized Official - Middle Name:T
Authorized Official - Last Name:COPPAGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-745-7935
Mailing Address - Street 1:650 COLISEUM PL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-3867
Mailing Address - Country:US
Mailing Address - Phone:478-745-7935
Mailing Address - Fax:478-745-7806
Practice Address - Street 1:650 COLISEUM PL
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3867
Practice Address - Country:US
Practice Address - Phone:478-745-7935
Practice Address - Fax:478-745-7806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1734Medicare ID - Type UnspecifiedPHYSCIAN GROUP PRACTICE