Provider Demographics
NPI:1871533877
Name:MYERS, MELLAYNE R (MD)
Entity type:Individual
Prefix:
First Name:MELLAYNE
Middle Name:R
Last Name:MYERS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:4660 RIVERSIDE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1395
Mailing Address - Country:US
Mailing Address - Phone:478-474-2114
Mailing Address - Fax:478-474-5043
Practice Address - Street 1:4660 RIVERSIDE PARK BLVD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1395
Practice Address - Country:US
Practice Address - Phone:478-474-2114
Practice Address - Fax:478-474-5043
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA048447207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000872858AMedicaid
C73985Medicare UPIN
GA25BBFPQMedicare ID - Type Unspecified