Provider Demographics
NPI:1780865477
Name:ALLERGY & ASTHMA CLINIC OF MACON
Entity Type:Organization
Organization Name:ALLERGY & ASTHMA CLINIC OF MACON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:PLAXICO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-743-9376
Mailing Address - Street 1:2076 INGLESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2028
Mailing Address - Country:US
Mailing Address - Phone:478-743-9376
Mailing Address - Fax:478-743-4670
Practice Address - Street 1:2076 INGLESIDE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2028
Practice Address - Country:US
Practice Address - Phone:478-743-9376
Practice Address - Fax:478-743-4670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022621174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000270905AMedicaid
GAD30479OtherUPIN
GA$$$$$$$$$OtherSOCIAL SECURITY NUMBER
GA010001168OtherRAILROAD MEDICARE
GA=========OtherTAX I.D.