Basic Information
| Provider Information | |||||||||
| NPI: | 1396764429 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2490 RIVERSIDE DR | ||||||||
| Address2: | STE B | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312041787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786336633 | ||||||||
| FaxNumber: | 4786334295 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 HEMLOCK ST | ||||||||
| Address2: | MSC 142 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786337707 | ||||||||
| FaxNumber: | 4786337879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 11/24/2014 | ||||||||
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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 | 207P00000X | 26979 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 059239 | GA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 602834254D | 05 | GA | MEDICAID |