Provider Demographics
NPI:1619616117
Name:EIDSON, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:EIDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3148 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2377
Mailing Address - Country:US
Mailing Address - Phone:404-520-3790
Mailing Address - Fax:
Practice Address - Street 1:110 WOODFIELD DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5625
Practice Address - Country:US
Practice Address - Phone:478-475-7988
Practice Address - Fax:478-475-7974
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-02
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT015914225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist