Healthcare Provider Details

I. General information

NPI: 1669602280
Provider Name (Legal Business Name): MPPG, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 MEMORIAL LN SUITE 500
SAVANNAH GA
31410-1254
US

IV. Provider business mailing address

PO BOX 102032
ATLANTA GA
30368-2032
US

V. Phone/Fax

Practice location:
  • Phone: 912-897-4604
  • Fax: 912-897-4608
Mailing address:
  • Phone: 912-897-4604
  • Fax: 912-897-4608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. ROBIN J MADDOX
Title or Position: PROVIDER ENROLLMENT COORDINATOR
Credential:
Phone: 912-350-9335