Healthcare Provider Details

I. General information

NPI: 1376813451
Provider Name (Legal Business Name): MIP MEDICAL MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2012
Last Update Date: 02/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 WALNUT ST
MACON GA
31201-2617
US

IV. Provider business mailing address

833 WALNUT ST
MACON GA
31201-2617
US

V. Phone/Fax

Practice location:
  • Phone: 478-741-5901
  • Fax: 478-741-5904
Mailing address:
  • Phone: 478-741-5901
  • Fax: 478-741-5904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number45394335
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number459343135
License Number StateGA

VIII. Authorized Official

Name: MS. CYNTHIA MARIE TATE
Title or Position: ADMINISTRATOR
Credential: CWCP
Phone: 478-741-5901