Provider Demographics
NPI:1053599043
Name:MAC - MACON ROAD LLC
Entity type:Organization
Organization Name:MAC - MACON ROAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:O'NEIL
Authorized Official - Last Name:SNODDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-243-3051
Mailing Address - Street 1:PO BOX 84052
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31908-4052
Mailing Address - Country:US
Mailing Address - Phone:706-243-0626
Mailing Address - Fax:
Practice Address - Street 1:3465 MACON RD STE D
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-2582
Practice Address - Country:US
Practice Address - Phone:706-243-3051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLUMBUS CLINIC, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-01
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA934157678AMedicaid
GA511G700243Medicare PIN