Provider Demographics
NPI:1922473859
Name:MACON GYNECOLOGIC ONCOLOGY LLC
Entity Type:Organization
Organization Name:MACON GYNECOLOGIC ONCOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-845-7630
Mailing Address - Street 1:770 PINE ST STE 210
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7512
Mailing Address - Country:US
Mailing Address - Phone:478-845-7630
Mailing Address - Fax:478-216-9178
Practice Address - Street 1:770 PINE ST STE 210
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7512
Practice Address - Country:US
Practice Address - Phone:478-845-7630
Practice Address - Fax:478-216-9178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA73005207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty