Healthcare Provider Details

I. General information

NPI: 1508000332
Provider Name (Legal Business Name): JEREMY JACOB PRINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 10/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 RIVERSIDE DR BLDG C
MACON GA
31210-2550
US

IV. Provider business mailing address

3200 RIVERSIDE DR BLDG C
MACON GA
31210-2550
US

V. Phone/Fax

Practice location:
  • Phone: 478-474-2947
  • Fax: 478-971-4004
Mailing address:
  • Phone: 478-474-2947
  • Fax: 478-971-4004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number071618
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number071618
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberL071618
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: