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General NPI Number Information
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NPI Number | 1528186913
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Entity Type | Organization
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Legal Business Name | MIDSTATE FAMILY MEDICINE, PC
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 10/18/2009
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Provider Practice Location Address
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Address Line | 2191 INGLESIDE AVE
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City | MACON
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State | GA
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Zip | 31204-2029
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Country | US
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Telephone | 478-745-0095
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Fax | 478-745-8138
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Provider Business Mailing Address
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Address Line | PO BOX 9542
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City | WARNER ROBINS
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State | GA
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Zip | 31095-9542
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Country | US
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Telephone | 478-745-0095
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Fax | 478-745-8138
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CAROL N PRYBY
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Credential | MD
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Telephone | 478-745-0095
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 46215
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License Number State | GA
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