Provider Demographics
NPI:1437815826
Name:INTERNAL MEDICINE OF MACON GA LLC
Entity type:Organization
Organization Name:INTERNAL MEDICINE OF MACON GA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:UKPONG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:478-746-0901
Mailing Address - Street 1:770 PINE ST STE 210
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7512
Mailing Address - Country:US
Mailing Address - Phone:478-746-0901
Mailing Address - Fax:478-250-8395
Practice Address - Street 1:770 PINE ST STE 210
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7512
Practice Address - Country:US
Practice Address - Phone:478-746-0901
Practice Address - Fax:478-250-8395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-10
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty