Healthcare Provider Details

I. General information

NPI: 1629356670
Provider Name (Legal Business Name): PEDIATRIC PULMONOLOGY OF CENTRAL GA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2011
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1062 FORSYTH ST SUITE 2 C
MACON GA
31201-8637
US

IV. Provider business mailing address

1062 FORSYTH ST SUITE 2 C
MACON GA
31201-8637
US

V. Phone/Fax

Practice location:
  • Phone: 478-755-0036
  • Fax: 478-755-1254
Mailing address:
  • Phone: 478-755-0036
  • Fax: 478-755-1254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMMY R COBB
Title or Position: BILLING MGR
Credential:
Phone: 478-755-0036