Provider Demographics
NPI:1912327263
Name:MIDDLE GEORGIA PULMONARY, LLC
Entity Type:Organization
Organization Name:MIDDLE GEORGIA PULMONARY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MAYA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOSEIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-748-3685
Mailing Address - Street 1:2024 WATSON BLVD
Mailing Address - Street 2:BLDG# 1
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-3624
Mailing Address - Country:US
Mailing Address - Phone:404-600-1215
Mailing Address - Fax:478-293-1559
Practice Address - Street 1:2024 WATSON BLVD
Practice Address - Street 2:BLDG# 1
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3624
Practice Address - Country:US
Practice Address - Phone:478-449-5030
Practice Address - Fax:478-293-1559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063470207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA869760044AMedicaid
GA869760044AMedicaid