Provider Demographics
NPI:1013234541
Name:PAUL R. PHELPS, SR, M.D., PC
Entity Type:Organization
Organization Name:PAUL R. PHELPS, SR, M.D., PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-254-5943
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-23
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011990207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA011990OtherSTATE LICENSE
GA00071398AMedicaid
GA00071398AMedicaid
GA202G028502Medicare PIN