Healthcare Provider Details

I. General information

NPI: 1124036934
Provider Name (Legal Business Name): GE YE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 04/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 VINEVILLE AVE
MACON GA
31204-3124
US

IV. Provider business mailing address

145 RIVER VALLEY TRL
KATHLEEN GA
31047-2139
US

V. Phone/Fax

Practice location:
  • Phone: 478-742-3631
  • Fax:
Mailing address:
  • Phone: 478-997-9485
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number003589
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD001232
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: