MEDICARE: WASHINGTON INTERNAL MEDICINE 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	040656	GA

General Provider Information

NPI Number	:	1346409927
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHINGTON INTERNAL MEDICINE LLC

Provider Business Mailing Address
First Line	:	PO BOX 26040
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31221-6040
Country	:	US
Telephone Number	:	478-475-1299
Fax Number	:	478-405-7928

Provider Business Practice Location Address
First Line	:	22 W ROBERT TOOMBS AVE
Second Line	:
City	:	WASHINGTON
State	:	GA
Zip	:	30673-1662
Country	:	US
Telephone Number	:	706-678-4785
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KIRKLAND T DODSON
Credential	:	MD
Telephone Number	:	706-678-4785

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	10/28/2009

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