Provider Demographics
NPI:1366551624
Name:CENTRAL GEORGIA CANCER CARE PC
Entity type:Organization
Organization Name:CENTRAL GEORGIA CANCER CARE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:478-743-7068
Mailing Address - Street 1:800 1ST ST STE 415
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-8300
Mailing Address - Country:US
Mailing Address - Phone:478-314-1667
Mailing Address - Fax:478-743-7068
Practice Address - Street 1:800 1ST ST STE 415
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8300
Practice Address - Country:US
Practice Address - Phone:478-314-1667
Practice Address - Fax:478-743-7068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0090113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA820880150AMedicaid
2016383OtherPK
2016383OtherPK