Basic Information
| Provider Information | |||||||||
| NPI: | 1467428128 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ACKERMANN | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3780 EISENHOWER PKWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312060800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786335500 | ||||||||
| FaxNumber: | 4787843550 | ||||||||
| Practice Location | |||||||||
| Address1: | 3780 EISENHOWER PKWY | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312060800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786335500 | ||||||||
| FaxNumber: | 4787843550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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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 | 207Q00000X | 034759 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QG0300X | 034759 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000478035H | 05 | GA | MEDICAID | 000478035I | 05 | GA | MEDICAID |