Healthcare Provider Details

I. General information

NPI: 1104866599
Provider Name (Legal Business Name): MACON CARDIOVASCULAR INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 1ST ST
MACON GA
31201-2825
US

IV. Provider business mailing address

575 1ST ST
MACON GA
31201-2825
US

V. Phone/Fax

Practice location:
  • Phone: 478-743-9762
  • Fax: 478-746-6612
Mailing address:
  • Phone: 478-743-9762
  • Fax: 478-746-6612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. LUCY F DERMO
Title or Position: BUSINESS MANAGER
Credential:
Phone: 478-743-9762