MEDICARE: MIDSTATE FAMILY MEDICINE, PC

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	46215	GA

General Provider Information

NPI Number	:	1528186913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDSTATE FAMILY MEDICINE, PC

Provider Business Mailing Address
First Line	:	PO BOX 9542
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31095-9542
Country	:	US
Telephone Number	:	478-745-0095
Fax Number	:	478-745-8138

Provider Business Practice Location Address
First Line	:	2191 INGLESIDE AVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-2029
Country	:	US
Telephone Number	:	478-745-0095
Fax Number	:	478-745-8138

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CAROL N PRYBY
Credential	:	MD
Telephone Number	:	478-745-0095

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	10/18/2009

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