Healthcare Provider Details

I. General information

NPI: 1083860779
Provider Name (Legal Business Name): MEDICAL GROUP OF CENTRAL GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2008
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2054 WATSON BLVD
WARNER ROBINS GA
31093-3634
US

IV. Provider business mailing address

PO BOX 5048
MACON GA
31208-5048
US

V. Phone/Fax

Practice location:
  • Phone: 478-918-0770
  • Fax: 478-918-0771
Mailing address:
  • Phone: 478-918-0770
  • Fax: 478-918-0771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHAMMAD N AL-SHROOF
Title or Position: OWNER
Credential: M.D.
Phone: 478-918-0770