Provider Demographics
NPI:1770511180
Name:SIMMONS, MARCUS L (MD)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:L
Last Name:SIMMONS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5569 HOUSTON RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-5709
Mailing Address - Country:US
Mailing Address - Phone:478-781-5065
Mailing Address - Fax:478-781-0012
Practice Address - Street 1:5569 HOUSTON RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31216-5709
Practice Address - Country:US
Practice Address - Phone:478-781-5065
Practice Address - Fax:478-781-0012
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049946207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000863475CMedicaid
GA00863475BMedicaid
GA202167625OtherFEDERAL TAX ID
GA00863475BMedicaid
GAH15702Medicare UPIN
GA11BDTGKMedicare ID - Type Unspecified