1780244301 NPI number — HEART OF GEORGIA PRIMARY CARE, LLC

Table of content: (NPI 1780244301)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780244301 NPI number — HEART OF GEORGIA PRIMARY CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEART OF GEORGIA PRIMARY CARE, LLC
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:
1780244301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
911 PLAZA AVE STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EASTMAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31023-6786
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-374-5774
Provider Business Mailing Address Fax Number:
912-374-9112

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 PLAZA AVE STE C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EASTMAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31023-6786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-374-5774
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2019

Additional Information

Authorized Official

Authorized Official Last Name:
CRAVEY
Authorized Official First Name:
AMY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
478-374-5774

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 296546508F , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CS2005900319 . This is a "CARESOURCE PROVIDER NUMBER" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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