MEDICARE: ALLERGY & ASTHMA CLINIC OF MACON

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	174400000X	Specialist	022621	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	010001168	OTHER	GA	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	D30479	OTHER	GA	UPIN
3	$$$$$$$$$	OTHER	GA	SOCIAL SECURITY NUMBER

General Provider Information

NPI Number	:	1780865477
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLERGY & ASTHMA CLINIC OF MACON

Provider Business Mailing Address
First Line	:	2076 INGLESIDE AVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-2028
Country	:	US
Telephone Number	:	478-743-9376
Fax Number	:	478-743-4670

Provider Business Practice Location Address
First Line	:	2076 INGLESIDE AVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-2028
Country	:	US
Telephone Number	:	478-743-9376
Fax Number	:	478-743-4670

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID T PLAXICO
Credential	:	M.D
Telephone Number	:	478-743-9376

Provider Enumeration Date	:	11/21/2007
Last Update Date	:	05/21/2020

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