Healthcare Provider Details

I. General information

NPI: 1962750323
Provider Name (Legal Business Name): JUSTIN MCIVOR LAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 COLEMAN AVE
MACON GA
31207-0001
US

IV. Provider business mailing address

1400 COLEMAN AVE
MACON GA
31207-0001
US

V. Phone/Fax

Practice location:
  • Phone: 478-301-2700
  • Fax:
Mailing address:
  • Phone: 478-301-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number72978
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number076754
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: