Provider Demographics
NPI:1356762553
Name:EDWARD D CONNER MD PC
Entity type:Organization
Organization Name:EDWARD D CONNER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:DARRELL
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-747-9474
Mailing Address - Street 1:112 GLENEAGLES CIR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2943
Mailing Address - Country:US
Mailing Address - Phone:478-747-9474
Mailing Address - Fax:
Practice Address - Street 1:112 GLENEAGLES CIR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2943
Practice Address - Country:US
Practice Address - Phone:478-747-9474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0350272080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1821045808Medicaid