Provider Demographics
NPI:1972785475
Name:SOUTH MACON FAMILY PHYSICIANS CLINIC
Entity Type:Organization
Organization Name:SOUTH MACON FAMILY PHYSICIANS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:P
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-781-2992
Mailing Address - Street 1:3741 HOUSTON AVE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31206-2415
Mailing Address - Country:US
Mailing Address - Phone:478-781-2992
Mailing Address - Fax:478-781-7152
Practice Address - Street 1:3741 HOUSTON AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-2415
Practice Address - Country:US
Practice Address - Phone:478-781-2992
Practice Address - Fax:478-781-7152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP1070Medicare PIN