Healthcare Provider Details

I. General information

NPI: 1497822324
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: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 WATERS AVE SUITE 202
SAVANNAH GA
31404-6200
US

IV. Provider business mailing address

4750 WATERS AVE SUITE 202
SAVANNAH GA
31404-6200
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-7412
  • Fax: 912-350-7297
Mailing address:
  • Phone: 912-350-7412
  • Fax: 912-350-7297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 7
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