MEDICARE: PROVIDENCE MEDICAL GROUP, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	051703	GA

General Provider Information

NPI Number	:	1063570604
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROVIDENCE MEDICAL GROUP, PC

Provider Business Mailing Address
First Line	:	PO BOX 4047
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31208-4047
Country	:	US
Telephone Number	:	404-856-3213
Fax Number	:	404-856-3217

Provider Business Practice Location Address
First Line	:	550 PEACHTREE ST NE
Second Line	:	SUITE 1285
City	:	ATLANTA
State	:	GA
Zip	:	30308-2249
Country	:	US
Telephone Number	:	404-856-3213
Fax Number	:	404-856-3217

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. OLADAYO ADISA OSINUGA
Credential	:	MD
Telephone Number	:	404-684-7111

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	06/19/2012

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