Provider Demographics
NPI:1063570604
Name:PROVIDENCE MEDICAL GROUP, PC
Entity type:Organization
Organization Name:PROVIDENCE MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLADAYO
Authorized Official - Middle Name:ADISA
Authorized Official - Last Name:OSINUGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-684-7111
Mailing Address - Street 1:PO BOX 4047
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4047
Mailing Address - Country:US
Mailing Address - Phone:404-856-3213
Mailing Address - Fax:404-856-3217
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:SUITE 1285
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2249
Practice Address - Country:US
Practice Address - Phone:404-856-3213
Practice Address - Fax:404-856-3217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051703207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty