Healthcare Provider Details

I. General information

NPI: 1639450877
Provider Name (Legal Business Name): MERCYMED OF COLUMBUS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3702 2ND AVENUE
COLUMBUS GA
31904
US

IV. Provider business mailing address

3702 2ND AVE
COLUMBUS GA
31904-7408
US

V. Phone/Fax

Practice location:
  • Phone: 706-507-9209
  • Fax:
Mailing address:
  • Phone: 706-507-9209
  • Fax: 706-507-9249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number58922
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number58922
License Number StateGA

VIII. Authorized Official

Name: MR. TONY NGUYEN
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 706-507-9209