Provider Demographics
NPI:1366899189
Name:MCC INTERNAL MEDICINE 2, LLC
Entity type:Organization
Organization Name:MCC INTERNAL MEDICINE 2, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAYER RELATIONS LIAISON
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-579-2626
Mailing Address - Street 1:PO BOX 468329
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31146-8329
Mailing Address - Country:US
Mailing Address - Phone:770-579-2626
Mailing Address - Fax:866-499-4593
Practice Address - Street 1:6501 PEAKE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-8042
Practice Address - Country:US
Practice Address - Phone:478-273-2662
Practice Address - Fax:478-246-0637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA66228174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty