MEDICARE: DR. MARCY MARIE MCKIBBIN O.D.

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	152W00000X	Optometrist	OPT002665	GA

General Provider Information

NPI Number	:	1437439072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARCY MARIE MCKIBBIN O.D.

Provider Business Mailing Address
First Line	:	2420 ECHO DR NE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30345-3527
Country	:	US
Telephone Number	:	901-351-7899
Fax Number	:

Provider Business Practice Location Address
First Line	:	3200 COBB GALLERIA PKWY STE 105
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30339-5919
Country	:	US
Telephone Number	:	901-351-7899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/26/2011
Last Update Date	:	08/26/2011

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