Healthcare Provider Details

I. General information

NPI: 1760541080
Provider Name (Legal Business Name): MPPG, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 10/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 OKATIE CENTER BLVD S SUITE 101
OKATIE SC
29909-7506
US

IV. Provider business mailing address

14 OKATIE CENTER BLVD S SUITE 101
OKATIE SC
29909-7506
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 TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number
License Number State

VIII. Authorized Official

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