Provider Demographics
NPI:1831272988
Name:OB-GYN ASSOCIATES OF WAYCROSS, PLLC
Entity type:Organization
Organization Name:OB-GYN ASSOCIATES OF WAYCROSS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MALMBORG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-285-2620
Mailing Address - Street 1:1206 ALICE STREET
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501
Mailing Address - Country:US
Mailing Address - Phone:912-285-2620
Mailing Address - Fax:912-285-7578
Practice Address - Street 1:1206 ALICE STREET
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501
Practice Address - Country:US
Practice Address - Phone:912-285-2620
Practice Address - Fax:912-285-7578
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X
GA18925207V00000X
GA042055207V00000X
GA19074207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD30129Medicare UPIN
GAD30095Medicare UPIN
GAH06253Medicare UPIN