Provider Demographics
NPI:1689857542
Name:DR. BOLANLE SOGADE M.D. LLC
Entity type:Organization
Organization Name:DR. BOLANLE SOGADE M.D. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-745-3014
Mailing Address - Street 1:639 HEMLOCK ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-6886
Mailing Address - Country:US
Mailing Address - Phone:478-745-3014
Mailing Address - Fax:478-745-9887
Practice Address - Street 1:639 HEMLOCK ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-6886
Practice Address - Country:US
Practice Address - Phone:478-745-3014
Practice Address - Fax:478-745-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047875207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA322090OtherWELLCARE
GAH89345Medicare UPIN