Provider Demographics
NPI:1619138146
Name:MIDDLE GEORGIA EAR NOSE & THROAT SURGERY CENTER, P.C.
Entity Type:Organization
Organization Name:MIDDLE GEORGIA EAR NOSE & THROAT SURGERY CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKHART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-452-6610
Mailing Address - Street 1:111 FIELDSTONE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-7106
Mailing Address - Country:US
Mailing Address - Phone:478-452-6610
Mailing Address - Fax:478-453-0745
Practice Address - Street 1:111 FIELDSTONE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-7106
Practice Address - Country:US
Practice Address - Phone:478-452-6610
Practice Address - Fax:478-453-0745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035287174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00494755AMedicaid
GA00494755AMedicaid