Healthcare Provider Details

I. General information

NPI: 1053627703
Provider Name (Legal Business Name): NEOCARE OF CENTRAL GEORGIA, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3203 VINEVILLE AVE
MACON GA
31204-2323
US

IV. Provider business mailing address

3203 VINEVILLE AVE STE A
MACON GA
31204-2323
US

V. Phone/Fax

Practice location:
  • Phone: 478-471-0273
  • Fax: 478-471-1471
Mailing address:
  • Phone: 478-471-0273
  • Fax: 478-471-1471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number076861
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. IRENE HO
Title or Position: OFFICE MANAGER
Credential: PA-C, MBA
Phone: 478-471-0273