=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225301781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDDLE GEORGIA INTERNAL MEDICINE & KIDNEY DISEASES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2012
-----------------------------------------------------
Last Update Date | 02/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1122 GRAY HWY SUITE 4
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31211-1869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-745-8309
-----------------------------------------------------
Fax | 478-745-8364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1122 GRAY HWY SUITE 4
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31211-1869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-745-8309
-----------------------------------------------------
Fax | 478-745-8364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. JANET A ALLEN-NWOSU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 478-745-8309
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | 33504
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------