Healthcare Provider Details

I. General information

NPI: 1497103824
Provider Name (Legal Business Name): COREY FUSSELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2016
Last Update Date: 01/17/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 HARMONY XING STE 1
EATONTON GA
31024-9548
US

IV. Provider business mailing address

250 MARTIN LUTHER KING JR BLVD
MACON GA
31201-3490
US

V. Phone/Fax

Practice location:
  • Phone: 762-320-2100
  • Fax:
Mailing address:
  • Phone: 478-301-4111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number82311
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: