Basic Information
| Provider Information | |||||||||
| NPI: | 1073589909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDDY | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 PINE ST | ||||||||
| Address2: | STE 760 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786336090 | ||||||||
| FaxNumber: | 4786332175 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 PINE ST | ||||||||
| Address2: | STE 760 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786336090 | ||||||||
| FaxNumber: | 4786332175 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 09/21/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | 050616 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | 000920598C | 05 | GA | MEDICAID |