Provider Demographics
NPI:1285837716
Name:NICHOLAS A PIETRZAK, MD, LLC
Entity Type:Organization
Organization Name:NICHOLAS A PIETRZAK, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-757-1934
Mailing Address - Street 1:3951 RIDGE AVE
Mailing Address - Street 2:STE B
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5050
Mailing Address - Country:US
Mailing Address - Phone:478-757-1934
Mailing Address - Fax:478-757-1596
Practice Address - Street 1:3951 RIDGE AVE
Practice Address - Street 2:STE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5050
Practice Address - Country:US
Practice Address - Phone:478-757-1934
Practice Address - Fax:478-757-1596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044308207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00834413DMedicaid
GAH00697Medicare UPIN
GA00834413DMedicaid