Individual
MR. RALLIE D COGBURN SR.
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
6070 LAKESIDE COMMONS DR, MACON, GA 31210-5778
(478) 254-2644
(478) 254-4924
Mailing address
PO BOX 26790, MACON, GA 31221-6790
(478) 254-2644
(478) 254-4924
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
003476
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00317358L
—
GA
05
—
100002802A
—
GA
05
—
100002802B
—
GA
Enumeration date
06/16/2005
Last updated
10/03/2014
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