=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891918264
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUBLIN-MACON CARDIOLOGY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 07/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 206A HOSPITAL DR
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31021-2989
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-272-3525
-----------------------------------------------------
Fax | 478-272-3589
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 16700
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31040-6700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-272-3525
-----------------------------------------------------
Fax | 478-272-3504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/ OWNER
-----------------------------------------------------
Name | DR. MANUEL A VEGA
-----------------------------------------------------
Credential | MD, FACC,FSCAI
-----------------------------------------------------
Telephone | 478-272-3525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0011X
-----------------------------------------------------
Taxonomy Name | Interventional Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207UN0901X
-----------------------------------------------------
Taxonomy Name | Nuclear Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------