Basic Information
| Provider Information | |||||||||
| NPI: | 1861569097 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MPPG, INC. | ||||||||
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| OtherOrganizationName: | SURGICAL SPECIALIST OF SAVANNAH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102032 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508712 | ||||||||
| FaxNumber: | 9123508753 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 S MAIN ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | HINESVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313134353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508712 | ||||||||
| FaxNumber: | 9123508753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2006 | ||||||||
| LastUpdateDate: | 08/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | MADDOX | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9123509335 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
No ID Information.