Provider Demographics
NPI:1922034198
Name:HEART OF GEORGIA MEDICAL ASSOCIATES,LLC
Entity type:Organization
Organization Name:HEART OF GEORGIA MEDICAL ASSOCIATES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:BRADY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-953-0911
Mailing Address - Street 1:320 MARGIE DR
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-7817
Mailing Address - Country:US
Mailing Address - Phone:478-953-0911
Mailing Address - Fax:478-953-0900
Practice Address - Street 1:320 MARGIE DR
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-7817
Practice Address - Country:US
Practice Address - Phone:478-953-0911
Practice Address - Fax:478-953-0900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033534207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000503676CMedicaid
GADE9769Medicare PIN
GAGRP7719Medicare PIN