Provider Demographics
NPI:1518476738
Name:GEORGIA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:GEORGIA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-345-8056
Mailing Address - Street 1:2410 INGLESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2036
Mailing Address - Country:US
Mailing Address - Phone:478-345-8056
Mailing Address - Fax:
Practice Address - Street 1:2410 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2036
Practice Address - Country:US
Practice Address - Phone:478-345-8056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGIA PHYSICIANS FOR ACC SOLE M
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty