Provider Demographics
NPI:1174705495
Name:BAINBRIDGE MEDICAL ASSOCIATES, PC
Entity type:Organization
Organization Name:BAINBRIDGE MEDICAL ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MALLORY
Authorized Official - Last Name:MCRAE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-248-8580
Mailing Address - Street 1:1518 MILULI AVE
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-4866
Mailing Address - Country:US
Mailing Address - Phone:229-248-8500
Mailing Address - Fax:229-248-8600
Practice Address - Street 1:1518 MILULI AVE
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-4866
Practice Address - Country:US
Practice Address - Phone:229-248-8500
Practice Address - Fax:229-248-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6258OtherMEDICARE