Basic Information
| Provider Information | |||||||||
| NPI: | 1912914847 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MACON MEDICAL GROUP PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 640 MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312013206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787455455 | ||||||||
| FaxNumber: | 4787452915 | ||||||||
| Practice Location | |||||||||
| Address1: | 640 MARTIN LUTHER KING JR BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312013206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787455455 | ||||||||
| FaxNumber: | 4787452915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 05/04/2009 | ||||||||
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| AuthorizedOfficialLastName: | CAVALIERE | ||||||||
| AuthorizedOfficialFirstName: | LUDWIG | ||||||||
| AuthorizedOfficialMiddleName: | V. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4787455455 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | CB5310 | 01 | RXR MEDICARE | OTHER | 300025393H | 05 | GA | MEDICAID | 300025393D | 05 | GA | MEDICAID |