Provider Demographics
NPI:1578572293
Name:IM-PEDS PRIMARY CARE LLC
Entity Type:Organization
Organization Name:IM-PEDS PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:EVELYN
Authorized Official - Last Name:MCKINLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-841-2707
Mailing Address - Street 1:360 HOSPITAL DR STE 110
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31217-8052
Mailing Address - Country:US
Mailing Address - Phone:478-841-2707
Mailing Address - Fax:478-841-2708
Practice Address - Street 1:360 HOSPITAL DR
Practice Address - Street 2:BLDG D SUITE110
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217-3874
Practice Address - Country:US
Practice Address - Phone:478-841-2707
Practice Address - Fax:478-841-2708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051256207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000954005AMedicaid
GADF1259OtherRAILROAD MEDICARE
GAGRP7817Medicare PIN
GAH62336Medicare UPIN
GADF1259OtherRAILROAD MEDICARE