Healthcare Provider Details

I. General information

NPI: 1942567532
Provider Name (Legal Business Name): KYLE STAPLETON ADAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2012
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 COLLEGE ST
MACON GA
31207-0001
US

IV. Provider business mailing address

1550 COLLEGE ST
MACON GA
31207-0001
US

V. Phone/Fax

Practice location:
  • Phone: 478-301-2600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.36048
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: