=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972785475
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH MACON FAMILY PHYSICIANS CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2007
-----------------------------------------------------
Last Update Date | 12/05/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3741 HOUSTON AVE
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31206-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-781-2992
-----------------------------------------------------
Fax | 478-781-7152
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3741 HOUSTON AVE
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31206-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-781-2992
-----------------------------------------------------
Fax | 478-781-7152
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM P BROOKS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 478-781-2992
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 11935
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------