Provider Demographics
NPI:1205231636
Name:MIDDLE GEORGIA DIABETES ENDOCRINOLOGY WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:MIDDLE GEORGIA DIABETES ENDOCRINOLOGY WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RALLIE
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:COGBURN
Authorized Official - Suffix:SR
Authorized Official - Credentials:PA-C
Authorized Official - Phone:478-254-2644
Mailing Address - Street 1:PO BOX 26790
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-6790
Mailing Address - Country:US
Mailing Address - Phone:478-254-2644
Mailing Address - Fax:478-254-4924
Practice Address - Street 1:512 S HOUSTON LAKE RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-6308
Practice Address - Country:US
Practice Address - Phone:478-254-2644
Practice Address - Fax:478-254-4924
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDDLE GEORGIA HEART AND VASCULAR CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA66515207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty