Basic Information
Provider Information | |||||||||
NPI: | 1669465860 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KING | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | WESLEY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 250 MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312013490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4783012362 | ||||||||
FaxNumber: | 4783012272 | ||||||||
Practice Location | |||||||||
Address1: | 250 MARTIN LUTHER KING JR BLVD | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312013490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4783014111 | ||||||||
FaxNumber: | 4783015812 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2005 | ||||||||
LastUpdateDate: | 02/14/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 03/27/2006 | ||||||||
NPIReactivationDate: | 06/26/2006 | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | 021126 | GA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0200X | 021126 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
ID | Type | State | Issuer | Description | 021126 | 01 | GA | GEORGIA LICENSE | OTHER | 00347608A | 05 | GA |   | MEDICAID | 52071710 | 01 | GA | BCBS GEORGIA | OTHER | 581714951 | 01 | GA | CHAMPVA COMMERCIAL | OTHER | 58171495131061 | 01 | GA | CHAMPUSTRICARETRICARLIFE | OTHER |