MEDICARE: MACON OCCUPATIONAL MEDICINE

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	2083X0100X	Occupational Medicine Physician

General Provider Information

NPI Number	:	1669973186
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACON OCCUPATIONAL MEDICINE

Provider Business Mailing Address
First Line	:	124 3RD ST
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31201-3404
Country	:	US
Telephone Number	:	478-751-2925
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 STATE UNIVERSITY DR
Second Line	:
City	:	FORT VALLEY
State	:	GA
Zip	:	31030-4313
Country	:	US
Telephone Number	:	478-972-8900
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	LEONARD BEVILL
Credential	:
Telephone Number	:	478-751-2900

Provider Enumeration Date	:	02/21/2018
Last Update Date	:	02/21/2018

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