Provider Demographics
NPI:1912914847
Name:MACON MEDICAL GROUP PC
Entity Type:Organization
Organization Name:MACON MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUDWIG
Authorized Official - Middle Name:V
Authorized Official - Last Name:CAVALIERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-745-5455
Mailing Address - Street 1:640 MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3206
Mailing Address - Country:US
Mailing Address - Phone:478-745-5455
Mailing Address - Fax:478-745-2915
Practice Address - Street 1:640 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3206
Practice Address - Country:US
Practice Address - Phone:478-745-5455
Practice Address - Fax:478-745-2915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB5310OtherRXR MEDICARE
GA300025393HMedicaid
GA300025393DMedicaid
CB5310OtherRXR MEDICARE