Provider Demographics
NPI:1760636575
Name:PEDIATRIC CARE OF MACON, LLC
Entity Type:Organization
Organization Name:PEDIATRIC CARE OF MACON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-475-1006
Mailing Address - Street 1:3951 RIDGE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-5050
Mailing Address - Country:US
Mailing Address - Phone:478-475-1006
Mailing Address - Fax:478-475-0787
Practice Address - Street 1:3951 RIDGE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-5050
Practice Address - Country:US
Practice Address - Phone:478-475-1006
Practice Address - Fax:478-475-0787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020359208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty