1033314711 NPI number — WHEELER COUNTY FAMILY MEDICINE

Table of content: (NPI 1033314711)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033314711 NPI number — WHEELER COUNTY FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WHEELER COUNTY FAMILY MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033314711
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 MAPLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIDALIA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30474-8949
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-537-0616
Provider Business Mailing Address Fax Number:
912-537-0617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 MAPLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIDALIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30474-8949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-537-0616
Provider Business Practice Location Address Fax Number:
912-537-0617
Provider Enumeration Date:
06/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STILL
Authorized Official First Name:
ODELL
Authorized Official Middle Name:
P
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
912-537-0616

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  037085 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000347751C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000539624E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000539624K , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000631474A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 393478520A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000954533C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 644701462A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 091222821A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com