Provider Demographics
NPI:1700011244
Name:INFECTION SPECIALISTS OF MIDDLE GEORGIA, LLC
Entity Type:Organization
Organization Name:INFECTION SPECIALISTS OF MIDDLE GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MODUPE
Authorized Official - Middle Name:OLUWATOYIN
Authorized Official - Last Name:OGUNSAKIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-922-5122
Mailing Address - Street 1:1420 WATSON BLVD
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3446
Mailing Address - Country:US
Mailing Address - Phone:478-922-5122
Mailing Address - Fax:478-922-5221
Practice Address - Street 1:1420 WATSON BLVD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3446
Practice Address - Country:US
Practice Address - Phone:478-922-5122
Practice Address - Fax:478-922-5221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55136207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA721242214AMedicaid
GA11SCDCMMedicare PIN
GA721242214AMedicaid