MEDICARE: MID PHYSICIAN NETWORK (OH), LLC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1184137960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID PHYSICIAN NETWORK (OH), LLC

Provider Business Mailing Address
First Line	:	PO BOX 6760
Second Line	:
City	:	THOMASVILLE
State	:	GA
Zip	:	31758-6760
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5665 NEW NORTHSIDE DR STE 520
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30328-4617
Country	:	US
Telephone Number	:	855-879-4332
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	ADRIAN PAUL DAVIS
Credential	:
Telephone Number	:	855-879-4332

Provider Enumeration Date	:	11/15/2017
Last Update Date	:	11/15/2017

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