Healthcare Provider Details

I. General information

NPI: 1376610360
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: 06/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 WATERS AVE
SAVANNAH GA
31404-6220
US

IV. Provider business mailing address

PO BOX 102032
ATLANTA GA
30368-2032
US

V. Phone/Fax

Practice location:
  • Phone: 912-350-8180
  • Fax: 912-350-8427
Mailing address:
  • Phone: 912-350-8180
  • Fax: 912-350-8427

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number
License Number State

VIII. Authorized Official

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