Provider Demographics
NPI:1194733907
Name:JAIN, PRAVIN K (MD)
Entity type:Individual
Prefix:
First Name:PRAVIN
Middle Name:K
Last Name:JAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2564
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31203
Mailing Address - Country:US
Mailing Address - Phone:478-746-5644
Mailing Address - Fax:478-745-4849
Practice Address - Street 1:380 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 410
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31217
Practice Address - Country:US
Practice Address - Phone:478-746-5644
Practice Address - Fax:478-745-4849
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030794207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000412222MMedicaid
GA326171OtherWELLCARE
GA000412222SMedicaid
GA000412222QMedicaid
GA000412222RMedicaid
OK200133190AMedicaid
GAP00057932OtherRAILROAD MEDICARE
GA$$$$$$$$$OtherTRICARE
OKOK400609Medicare PIN
A61273Medicare UPIN
GA000412222RMedicaid