Basic Information
| Provider Information | |||||||||
| NPI: | 1740579390 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | MARIAN | ||||||||
| MiddleName: | SYMMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3696 WHEELER RD | ||||||||
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| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309096520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067361830 | ||||||||
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| Practice Location | |||||||||
| Address1: | 682 HEMLOCK ST STE 210 | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4786336090 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2011 | ||||||||
| LastUpdateDate: | 08/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0201X | 80122 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
No ID Information.