Provider Demographics
NPI:1578951190
Name:MIDDLE GEORGIA ALLERGY AND ASTHMA LLC
Entity Type:Organization
Organization Name:MIDDLE GEORGIA ALLERGY AND ASTHMA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-353-1058
Mailing Address - Street 1:229 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2969
Mailing Address - Country:US
Mailing Address - Phone:478-353-1058
Mailing Address - Fax:478-238-0841
Practice Address - Street 1:229 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2969
Practice Address - Country:US
Practice Address - Phone:478-353-1058
Practice Address - Fax:478-238-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-05
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64841207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003110844PMedicaid
GA202I032517OtherMEDICARE PTAN