Healthcare Provider Details

I. General information

NPI: 1912917642
Provider Name (Legal Business Name): MICHAEL LORADITCH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HEMLOCK ST HOSPITAL BOX 64
MACON GA
31201-2102
US

IV. Provider business mailing address

103 WALDORF DR
PERRY GA
31069-8741
US

V. Phone/Fax

Practice location:
  • Phone: 478-633-2097
  • Fax: 478-633-7836
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number002049
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: