Provider Demographics
NPI:1609199579
Name:MACON WOMENS HEALTH CLINIC, LLC
Entity Type:Organization
Organization Name:MACON WOMENS HEALTH CLINIC, LLC
Other - Org Name:FELISHA L. KITCHEN, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER & PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:FELISHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KITCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-742-5502
Mailing Address - Street 1:718 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6840
Mailing Address - Country:US
Mailing Address - Phone:478-742-5502
Mailing Address - Fax:478-742-5505
Practice Address - Street 1:718 1ST ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6840
Practice Address - Country:US
Practice Address - Phone:478-742-5502
Practice Address - Fax:478-742-5505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA560266765BMedicaid
GA739099977DMedicaid
GA739099977DMedicaid
GA560266765BMedicaid
GA16BBCJPMedicare PIN
GA202G700948Medicare UPIN