Healthcare Provider Details

I. General information

NPI: 1306923495
Provider Name (Legal Business Name): MACON ELECTROPHYSIOLOGY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 HEMLOCK STR STE 100
MACON GA
31201
US

IV. Provider business mailing address

639 HEMLOCK STR STE 100
MACON GA
31201
US

V. Phone/Fax

Practice location:
  • Phone: 478-755-1560
  • Fax: 478-755-1562
Mailing address:
  • Phone: 478-755-1560
  • Fax: 478-755-1562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number052807
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number061887
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number042444
License Number StateGA

VIII. Authorized Official

Name: KINDLE BUSBEE
Title or Position: ADMIN
Credential:
Phone: 478-755-1560