Provider Demographics
NPI:1669483889
Name:MIDDLE GEORGIA OB/GYN,PC
Entity type:Organization
Organization Name:MIDDLE GEORGIA OB/GYN,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:478-333-6901
Mailing Address - Street 1:P O BOX 8168
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31095-8168
Mailing Address - Country:US
Mailing Address - Phone:478-333-6901
Mailing Address - Fax:478-333-6907
Practice Address - Street 1:109 OSIGIAN BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8925
Practice Address - Country:US
Practice Address - Phone:478-333-6901
Practice Address - Fax:478-333-6907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050921207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000960924BMedicaid
GAH65644Medicare UPIN
GA000960924BMedicaid
GA16BBCQCMedicare PIN