Provider Demographics
NPI:1134756463
Name:TABB, MACY PHILLIPS (DO)
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:PHILLIPS
Last Name:TABB
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 E SHOTWELL ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4256
Mailing Address - Country:US
Mailing Address - Phone:229-246-3500
Mailing Address - Fax:
Practice Address - Street 1:505 AMELIA AVE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4355
Practice Address - Country:US
Practice Address - Phone:229-243-6900
Practice Address - Fax:229-243-6919
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA390200000X
GA95579207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program