Healthcare Provider Details

I. General information

NPI: 1760562268
Provider Name (Legal Business Name): BENJAMIN MAYS JOHNSTON, SR, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 FIRST STREET SUITE B
MACON GA
31201-6806
US

IV. Provider business mailing address

PO BOX 28170
MACON GA
31221-8170
US

V. Phone/Fax

Practice location:
  • Phone: 478-746-1717
  • Fax: 478-738-8639
Mailing address:
  • Phone: 478-254-5943
  • Fax: 478-254-6093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number018579
License Number StateGA

VIII. Authorized Official

Name: TAMMY J BRICKLE
Title or Position: BILLING AGENT
Credential:
Phone: 478-254-5943