Healthcare Provider Details

I. General information

NPI: 1740579390
Provider Name (Legal Business Name): MARIAN SYMMES JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 08/04/2021
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

682 HEMLOCK ST STE 210
MACON GA
31201
US

IV. Provider business mailing address

3696 WHEELER RD
AUGUSTA GA
30909-6520
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-6090
  • Fax:
Mailing address:
  • Phone: 706-736-1830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number80122
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: