Healthcare Provider Details

I. General information

NPI: 1295992568
Provider Name (Legal Business Name): OCMULGEE INTERNAL MEDICINE AND NEPHROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 PLAZA AVE
EASTMAN GA
31023-6785
US

IV. Provider business mailing address

911 PLAZA AVE
EASTMAN GA
31023-6785
US

V. Phone/Fax

Practice location:
  • Phone: 111-111-1111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: MIKE HESTER
Title or Position: CFO
Credential:
Phone: 478-448-4050