Healthcare Provider Details

I. General information

NPI: 1992890727
Provider Name (Legal Business Name): JACK R EADES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 05/17/2024
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 PEAKE RD STE 1000
MACON GA
31210-8052
US

IV. Provider business mailing address

6501 PEAKE RD STE 1000
MACON GA
31210-8052
US

V. Phone/Fax

Practice location:
  • Phone: 478-607-2514
  • Fax: 478-607-2513
Mailing address:
  • Phone: 478-607-2514
  • Fax: 478-607-2513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number20053
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number043360
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: