Healthcare Provider Details

I. General information

NPI: 1407015365
Provider Name (Legal Business Name): CENTRAL GEORGIA GYNECOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 PINE STREET SUITTE 580
MACON GA
31201-7532
US

IV. Provider business mailing address

P.O. BOX 27690
MACON GA
31221-7690
US

V. Phone/Fax

Practice location:
  • Phone: 478-960-7747
  • Fax: 478-746-0022
Mailing address:
  • Phone: 478-960-7747
  • Fax: 478-746-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. HENRY JACKSON DAVIS
Title or Position: PRESIDENT
Credential: MD
Phone: 478-960-7747