Provider Demographics
NPI:1114322575
Name:WELLPOINT MEDICAL SERVICES, PC
Entity Type:Organization
Organization Name:WELLPOINT MEDICAL SERVICES, PC
Other - Org Name:WELLPOINT MEDICAL SERVICES, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:T
Authorized Official - Last Name:SECURO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-328-6466
Mailing Address - Street 1:1533 WATSON BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3449
Mailing Address - Country:US
Mailing Address - Phone:478-328-6466
Mailing Address - Fax:478-328-1338
Practice Address - Street 1:1533 WATSON BLVD
Practice Address - Street 2:STE B
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3449
Practice Address - Country:US
Practice Address - Phone:478-328-6466
Practice Address - Fax:478-328-1338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051736261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051736OtherMEDICARE
GAH57207Medicare UPIN