Provider Demographics
NPI:1043319650
Name:HOUSE, ALICE ROSE (MD)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:ROSE
Last Name:HOUSE
Suffix:
Gender:F
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 4947
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4947
Mailing Address - Country:US
Mailing Address - Phone:478-301-2362
Mailing Address - Fax:478-301-2272
Practice Address - Street 1:1550 COLLEGE ST
Practice Address - Street 2:SUITE A
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31207-0001
Practice Address - Country:US
Practice Address - Phone:478-301-4111
Practice Address - Fax:478-301-5812
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043065207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA080188724OtherRAILROAD MEDICARE
GA000807364CMedicaid
GA080188724OtherRAILROAD MEDICARE
G69361Medicare UPIN
GA000807364CMedicaid