Basic Information
| Provider Information | |||||||||
| NPI: | 1376613570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EARLY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 AVERA DR | ||||||||
| Address2: | |||||||||
| City: | FORT VALLEY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310305008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4788253317 | ||||||||
| FaxNumber: | 4788255499 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 AVERA DR | ||||||||
| Address2: | |||||||||
| City: | FORT VALLEY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310305008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4788253317 | ||||||||
| FaxNumber: | 4788255499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 27806 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00307931A | 05 | GA | MEDICAID |