MEDICARE: MACMED LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	GA051731	GA
2	208M00000X	Hospitalist Physician	GA11411	GA
3	208D00000X	General Practice Physician	GA11411	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417062613
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACMED LLC

Provider Business Mailing Address
First Line	:	1606 REYNOLDS ST
Second Line	:
City	:	BRUNSWICK
State	:	GA
Zip	:	31520-6731
Country	:	US
Telephone Number	:	850-279-4917
Fax Number	:	850-279-4917

Provider Business Practice Location Address
First Line	:	2927 DEMERE RD
Second Line	:	ATTEN: DR ANDREW T MCRAE
City	:	ST SIMONS ISLAND
State	:	GA
Zip	:	31522-1620
Country	:	US
Telephone Number	:	912-638-1999
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JUDY S RIVENBARK
Credential	:	M.D.
Telephone Number	:	850-279-4917

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	08/29/2012

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Directions to “MACMED LLC ” Practice Location

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