Healthcare Provider Details

I. General information

NPI: 1972545267
Provider Name (Legal Business Name): LARRY M KOHSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 MARTIN LUTHER KING BOULEVARD
MACON GA
31201
US

IV. Provider business mailing address

PO BOX 4947
MACON GA
31208-4947
US

V. Phone/Fax

Practice location:
  • Phone: 478-301-4111
  • Fax: 478-301-5812
Mailing address:
  • Phone: 478-301-2362
  • Fax: 478-301-2272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number040442
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: