Provider Demographics
NPI:1376813451
Name:MIP MEDICAL MANAGEMENT
Entity Type:Organization
Organization Name:MIP MEDICAL MANAGEMENT
Other - Org Name:MACON MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:CWCP
Authorized Official - Phone:478-741-5901
Mailing Address - Street 1:833 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2617
Mailing Address - Country:US
Mailing Address - Phone:478-741-5901
Mailing Address - Fax:478-741-5904
Practice Address - Street 1:833 WALNUT ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2617
Practice Address - Country:US
Practice Address - Phone:478-741-5901
Practice Address - Fax:478-741-5904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-06
Last Update Date:2013-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207K00000X
GA45394335207R00000X
GA459343135208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA6706880001Medicare NSC