Healthcare Provider Details

I. General information

NPI: 1780865477
Provider Name (Legal Business Name): ALLERGY & ASTHMA CLINIC OF MACON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 05/21/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2076 INGLESIDE AVE
MACON GA
31204-2028
US

IV. Provider business mailing address

2076 INGLESIDE AVE
MACON GA
31204-2028
US

V. Phone/Fax

Practice location:
  • Phone: 478-743-9376
  • Fax: 478-743-4670
Mailing address:
  • Phone: 478-743-9376
  • Fax: 478-743-4670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number022621
License Number StateGA

VIII. Authorized Official

Name: DAVID T PLAXICO
Title or Position: OWNER
Credential: M.D
Phone: 478-743-9376