Healthcare Provider Details

I. General information

NPI: 1578572293
Provider Name (Legal Business Name): IM-PEDS PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 HOSPITAL DR BLDG D SUITE110
MACON GA
31217-3874
US

IV. Provider business mailing address

360 HOSPITAL DR STE 110
MACON GA
31217-8052
US

V. Phone/Fax

Practice location:
  • Phone: 478-841-2707
  • Fax: 478-841-2708
Mailing address:
  • Phone: 478-841-2707
  • Fax: 478-841-2708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number051256
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number051256
License Number StateGA

VIII. Authorized Official

Name: MARY EVELYN MCKINLEY
Title or Position: DOCTOR
Credential: MD
Phone: 478-841-2707