Basic Information
Provider Information
NPI: 1871646521
EntityType: 2
ReplacementNPI:  
OrganizationName: PODIATRIC MEDICAL ASSOCIATES
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 4144
Address2:  
City: MACON
State: GA
PostalCode: 312084144
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 770 PINE ST
Address2: SUITE 300
City: MACON
State: GA
PostalCode: 312012173
CountryCode: US
TelephoneNumber: 4786210877
FaxNumber: 4786215494
Other Information
ProviderEnumerationDate: 01/18/2007
LastUpdateDate: 03/24/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: WILLIAMSON
AuthorizedOfficialFirstName: RONDRICK
AuthorizedOfficialMiddleName: ESHON
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 4786210877
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: DPM
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
213E00000XPOD000931GAY193400000X SINGLE SPECIALTY GROUPPodiatric Medicine & Surgery Service ProvidersPodiatrist 

No ID Information.


Home