Provider Demographics
NPI:1821168931
Name:PHELPS, PAUL RAYMOND SR (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:RAYMOND
Last Name:PHELPS
Suffix:SR
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:P.O. BOX 28170
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-8170
Mailing Address - Country:US
Mailing Address - Phone:478-254-5943
Mailing Address - Fax:478-254-6093
Practice Address - Street 1:818 FORSYTH STREET
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2139
Practice Address - Country:US
Practice Address - Phone:478-633-7010
Practice Address - Fax:478-633-7585
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA011990207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00071398AMedicaid
GA00071398AMedicaid
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