Basic Information
| Provider Information | |||||||||
| NPI: | 1902962855 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POPLAR PHYSICIANS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 446 POPLAR ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312013336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787461218 | ||||||||
| FaxNumber: | 4787509594 | ||||||||
| Practice Location | |||||||||
| Address1: | 446 POPLAR ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312013336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787461218 | ||||||||
| FaxNumber: | 4787509594 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 09/02/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SHEPPARD | ||||||||
| AuthorizedOfficialFirstName: | JOHNNY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4787461218 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CE0448 | 01 | GA | RAILROAD MEDICARE | OTHER |