Provider Demographics
NPI:1346209426
Name:MACON PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MACON PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL VP OUTPATIENT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:ALOYSIUS
Authorized Official - Middle Name:F
Authorized Official - Last Name:MEIVES
Authorized Official - Suffix:IV
Authorized Official - Credentials:PT
Authorized Official - Phone:859-585-3002
Mailing Address - Street 1:3085 VINEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204
Mailing Address - Country:US
Mailing Address - Phone:478-742-0904
Mailing Address - Fax:478-352-0078
Practice Address - Street 1:3085 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204
Practice Address - Country:US
Practice Address - Phone:478-742-0904
Practice Address - Fax:478-352-0078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-19
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002335225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA65BBBDNMedicare ID - Type UnspecifiedPART B