Provider Demographics
NPI:1417062613
Name:MACMED LLC
Entity Type:Organization
Organization Name:MACMED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:RIVENBARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-279-4917
Mailing Address - Street 1:1606 REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-6731
Mailing Address - Country:US
Mailing Address - Phone:850-279-4917
Mailing Address - Fax:850-279-4917
Practice Address - Street 1:2927 DEMERE RD
Practice Address - Street 2:ATTEN: DR ANDREW T MCRAE
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-1620
Practice Address - Country:US
Practice Address - Phone:912-638-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA051731207Q00000X
GAGA11411208D00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300034700AMedicaid
GA300034700AMedicaid