Basic Information
| Provider Information | |||||||||
| NPI: | 1255609350 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAGI | ||||||||
| FirstName: | BUTHENA | ||||||||
| MiddleName: | AHMED | ||||||||
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| Credential: | M.D., M.B.CH.B. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 657 HEMLOCK ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312018311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787417241 | ||||||||
| FaxNumber: | 4787417241 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787417241 | ||||||||
| FaxNumber: | 4787458932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2011 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 73352 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003160889 | 05 | GA | MEDICAID |