Healthcare Provider Details

I. General information

NPI: 1285937060
Provider Name (Legal Business Name): GEORGIA DAVIS, M.D. AND ASSOCIATES L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 BEDFORD DR SUITE 101
MELBOURNE FL
32940-1987
US

IV. Provider business mailing address

1112 RICKARD RD SUITE B
SPRINGFIELD IL
62704-1017
US

V. Phone/Fax

Practice location:
  • Phone: 321-622-8114
  • Fax: 321-622-4649
Mailing address:
  • Phone: 217-787-9540
  • Fax: 217-787-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0036078693
License Number StateIL

VIII. Authorized Official

Name: MR. CHARLES JOSEPH MERTZ
Title or Position: BUSINESS MANAGER
Credential:
Phone: 217-787-9540