Healthcare Provider Details

I. General information

NPI: 1972923258
Provider Name (Legal Business Name): MAXINE OWUSU M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S 8TH ST
GRIFFIN GA
30224-4213
US

IV. Provider business mailing address

911 LAKESIDE VILLAS DRIVE 911
HAMPTON GA
30228
US

V. Phone/Fax

Practice location:
  • Phone: 770-228-2721
  • Fax:
Mailing address:
  • Phone: 315-395-7874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number78170
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: