Provider Demographics
NPI:1992890727
Name:EADES, JACK R (MD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:R
Last Name:EADES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6501 PEAKE RD STE 1000
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-8052
Mailing Address - Country:US
Mailing Address - Phone:478-607-2514
Mailing Address - Fax:478-607-2513
Practice Address - Street 1:6501 PEAKE RD STE 1000
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-8052
Practice Address - Country:US
Practice Address - Phone:478-607-2514
Practice Address - Fax:478-607-2513
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20053207K00000X
GA043360207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00751264DMedicaid
GA00751264FMedicaid
SCG43360Medicaid
GA00751264EMedicaid
GA03BCBPKMedicare PIN
GA00751264DMedicaid
SCF756890281Medicare PIN