Healthcare Provider Details

I. General information

NPI: 1649558537
Provider Name (Legal Business Name): TED HYDE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 07/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3715 VINEVILLE AVE
MACON GA
31204-1854
US

IV. Provider business mailing address

3715 VINEVILLE AVE
MACON GA
31204-1854
US

V. Phone/Fax

Practice location:
  • Phone: 478-474-8040
  • Fax: 478-474-8048
Mailing address:
  • Phone: 478-474-8040
  • Fax: 478-474-8048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: