Healthcare Provider Details

I. General information

NPI: 1578550760
Provider Name (Legal Business Name): BEN B NEELY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 N WASHINGTON ST
LYONS GA
30436-1179
US

IV. Provider business mailing address

PO BOX 626
LYONS GA
30436-0626
US

V. Phone/Fax

Practice location:
  • Phone: 912-526-6479
  • Fax: 912-526-8878
Mailing address:
  • Phone: 912-526-6479
  • Fax: 912-526-8878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number010249
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: