Healthcare Provider Details

I. General information

NPI: 1437815826
Provider Name (Legal Business Name): INTERNAL MEDICINE OF MACON GA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2021
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
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: 478-746-0901
  • Fax: 478-250-8395
Mailing address:
  • Phone: 478-746-0901
  • Fax: 478-250-8395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DANIEL UKPONG
Title or Position: DO
Credential: DO
Phone: 478-746-0901