Healthcare Provider Details

I. General information

NPI: 1912794777
Provider Name (Legal Business Name): SIDHARTH MISRA MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2025
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST
MACON GA
31201-2102
US

IV. Provider business mailing address

777 HEMLOCK ST
MACON GA
31201-2102
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-7500
  • Fax:
Mailing address:
  • Phone: 478-633-7500
  • Fax: 214-648-5250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number1346507
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: