Healthcare Provider Details

I. General information

NPI: 1922473859
Provider Name (Legal Business Name): MACON GYNECOLOGIC ONCOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 04/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 PINE ST STE 210
MACON GA
31201-7512
US

IV. Provider business mailing address

770 PINE ST STE 210
MACON GA
31201-7512
US

V. Phone/Fax

Practice location:
  • Phone: 478-845-7630
  • Fax: 478-216-9178
Mailing address:
  • Phone: 478-845-7630
  • Fax: 478-216-9178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0201X
TaxonomyGynecologic Oncology Physician
License Number73005
License Number StateGA

VIII. Authorized Official

Name: MICHAEL B DILLON
Title or Position: PROVIDER
Credential: MD
Phone: 478-845-7630