Provider Demographics
NPI:1619037009
Name:MPPG, INC.
Entity Type:Organization
Organization Name:MPPG, INC.
Other - Org Name:MEMORIAL HEALTH BLUFFTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MADDOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-350-9335
Mailing Address - Street 1:PO BOX 102032
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2032
Mailing Address - Country:US
Mailing Address - Phone:843-836-3800
Mailing Address - Fax:843-705-3828
Practice Address - Street 1:14 OKATIE CENTER BLVD. SOUTH
Practice Address - Street 2:SUITE 101
Practice Address - City:OKATIE
Practice Address - State:SC
Practice Address - Zip Code:29909
Practice Address - Country:US
Practice Address - Phone:843-836-3800
Practice Address - Fax:843-705-3828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300031676AMedicaid
SCCJ4583OtherRR MEDICARE GROUP
SCGP4223Medicaid
SCGRP7416Medicare PIN