Provider Demographics
NPI:1336256981
Name:MIDDLE GEORGIA ONCOLOGY, LLC
Entity Type:Organization
Organization Name:MIDDLE GEORGIA ONCOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:CARROLL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-272-9889
Mailing Address - Street 1:107 FAIRVIEW PARK DR
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2501
Mailing Address - Country:US
Mailing Address - Phone:478-272-9889
Mailing Address - Fax:478-272-9821
Practice Address - Street 1:107 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2501
Practice Address - Country:US
Practice Address - Phone:478-272-9889
Practice Address - Fax:478-272-9821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF86173Medicare UPIN