Healthcare Provider Details

I. General information

NPI: 1073680070
Provider Name (Legal Business Name): MPPG, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 WATERS AVE SUITE 108
SAVANNAH GA
31404-6200
US

IV. Provider business mailing address

4750 WATERS AVE SUITE 108
SAVANNAH GA
31404-6200
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-5940
  • Fax: 912-350-5991
Mailing address:
  • Phone: 912-350-5940
  • Fax: 912-350-5991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

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