MEDICARE: PHYSICIANS CARE CENTER 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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1194995647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICIANS CARE CENTER LLC

Provider Business Mailing Address
First Line	:	321 MCCALLUM PL
Second Line	:
City	:	LIZELLA
State	:	GA
Zip	:	31052-3814
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5569 HOUSTON RD
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31216-5709
Country	:	US
Telephone Number	:	478-935-9221
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MR. MICHAEL WUOLUKKA
Credential	:
Telephone Number	:	478-935-9221

Provider Enumeration Date	:	03/11/2008
Last Update Date	:	03/11/2008

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