Provider Demographics
NPI:1245544519
Name:MPPG, INC.
Entity type:Organization
Organization Name:MPPG, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SEBRENA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLMES GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-350-9335
Mailing Address - Street 1:PO BOX 102032
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2032
Mailing Address - Country:US
Mailing Address - Phone:912-350-7020
Mailing Address - Fax:912-756-2427
Practice Address - Street 1:3780 US HIGHWAY 17
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3378
Practice Address - Country:US
Practice Address - Phone:912-756-2292
Practice Address - Fax:912-756-2289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGPB007Medicaid