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NPI Code Detail

MEDICARE: TALLULAH TRAIL MEDICAL ASSOCIATES, LLC

MEDICARE: TALLULAH TRAIL MEDICAL ASSOCIATES, 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
1207R00000XInternal Medicine Physician

General Provider Information

NPI Number : 1720426075
Entity Type Code : Organization
Provider Name (Legal Business Name) : TALLULAH TRAIL MEDICAL ASSOCIATES, LLC
Provider Business Mailing Address
First Line : 644 TALLULAH TRL
Second Line :
City : WARNER ROBINS
State : GA
Zip : 31088-7625
Country : US
Telephone Number : 478-302-5270
Fax Number :
Provider Business Practice Location Address
First Line : 644 TALLULAH TRL
Second Line :
City : WARNER ROBINS
State : GA
Zip : 31088-7625
Country : US
Telephone Number : 478-302-5270
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : MR. NORMAN W KING
Credential :
Telephone Number : 478-302-5270
Provider Enumeration Date : 06/10/2013
Last Update Date : 06/10/2013

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