Provider Demographics
NPI:1871635516
Name:M. MICHAEL PULLIAM, M.D., P.C.
Entity Type:Organization
Organization Name:M. MICHAEL PULLIAM, M.D., P.C.
Other - Org Name:PULLIAM EYE GROUP/NEWTON ROCKDALE ASC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PULLIAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-786-1234
Mailing Address - Street 1:P.O. BOX 469
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30015-0469
Mailing Address - Country:US
Mailing Address - Phone:770-786-1234
Mailing Address - Fax:770-385-0813
Practice Address - Street 1:1467 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2565
Practice Address - Country:US
Practice Address - Phone:770-786-1234
Practice Address - Fax:770-385-0813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11036174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00012229DMedicaid
GA00164469KMedicaid
GA00164469IMedicaid
GA00164469JMedicaid
GA00420802AMedicaid
GA18BDCRRMedicare ID - Type UnspecifiedM. M. PULLIAM, MD
GA00164469KMedicaid
GAGRP1189Medicare ID - Type UnspecifiedCOVINGTON JACKSON
GA18BDFVVMedicare ID - Type UnspecifiedR. DEAS, MD
GAGRP1838Medicare ID - Type UnspecifiedMADISON
GA00164469JMedicaid
GAD41934Medicare UPIN
GA18BDFVWMedicare ID - Type UnspecifiedR.DEAS.MD
E59013Medicare UPIN