Provider Demographics
NPI:1407015365
Name:CENTRAL GEORGIA GYNECOLOGY LLC
Entity type:Organization
Organization Name:CENTRAL GEORGIA GYNECOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-960-7747
Mailing Address - Street 1:P.O. BOX 27690
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31221-7690
Mailing Address - Country:US
Mailing Address - Phone:478-960-7747
Mailing Address - Fax:478-746-0022
Practice Address - Street 1:770 PINE STREET
Practice Address - Street 2:SUITTE 580
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7532
Practice Address - Country:US
Practice Address - Phone:478-960-7747
Practice Address - Fax:478-746-0022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207V00000X
207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700775Medicare PIN