Healthcare Provider Details

I. General information

NPI: 1245236082
Provider Name (Legal Business Name): WILLIAM KEITH FACKLER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 SHERATON BLVD
MACON GA
31210-1358
US

IV. Provider business mailing address

240 SHERATON BLVD
MACON GA
31210-1358
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-8700
  • Fax: 478-633-8710
Mailing address:
  • Phone: 478-633-8702
  • Fax: 478-633-8710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number040830
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: