Provider Demographics
NPI:1780879957
Name:DOERUN HEALTHCARE L.L.C.
Entity type:Organization
Organization Name:DOERUN HEALTHCARE L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:MAC KEAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:229-782-5048
Mailing Address - Street 1:217 WEST BROAD AVE
Mailing Address - Street 2:PO BOX 459
Mailing Address - City:DOERUN
Mailing Address - State:GA
Mailing Address - Zip Code:31744-0459
Mailing Address - Country:US
Mailing Address - Phone:229-782-5048
Mailing Address - Fax:229-782-5049
Practice Address - Street 1:217 WEST BROAD AVE
Practice Address - Street 2:
Practice Address - City:DOERUN
Practice Address - State:GA
Practice Address - Zip Code:31744-0459
Practice Address - Country:US
Practice Address - Phone:229-782-5048
Practice Address - Fax:229-782-5049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN146046363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q60248Medicare UPIN