Basic Information
| Provider Information | |||||||||
| NPI: | 1962561811 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MPPG, INC. | ||||||||
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| OtherOrganizationName: | ENDOCRINOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102032 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123505908 | ||||||||
| FaxNumber: | 9123505914 | ||||||||
| Practice Location | |||||||||
| Address1: | 4750 WATERS AVE | ||||||||
| Address2: | SUITE 452 | ||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314046200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123505908 | ||||||||
| FaxNumber: | 9123505914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2006 | ||||||||
| LastUpdateDate: | 05/31/2011 | ||||||||
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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 | 133VN1006X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic | 207RE0101X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | GPA603 | 05 | SC | MEDICAID | 300031676A | 05 | GA | MEDICAID | CH5121 | 01 | GA | RR MEDICARE | OTHER |