Healthcare Provider Details

I. General information

NPI: 1174705495
Provider Name (Legal Business Name): BAINBRIDGE MEDICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1518 MILULI AVE
BAINBRIDGE GA
39819-4866
US

IV. Provider business mailing address

1518 MILULI AVE
BAINBRIDGE GA
39819-4866
US

V. Phone/Fax

Practice location:
  • Phone: 229-248-8500
  • Fax: 229-248-8600
Mailing address:
  • Phone: 229-248-8500
  • Fax: 229-248-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateGA

VIII. Authorized Official

Name: DR. JON MALLORY MCRAE
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 229-248-8580