Basic Information
| Provider Information | |||||||||
| NPI: | 1306356860 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MICHAEL | ||||||||
| FirstName: | JESSE | ||||||||
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| Credential: | AA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 HOSPITAL DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312178014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787465644 | ||||||||
| FaxNumber: | 4787454849 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 HOSPITAL DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312178014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787465644 | ||||||||
| FaxNumber: | 4787454849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2017 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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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 | 367H00000X | 008537 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | GA | MEDICAID |