Healthcare Provider Details

I. General information

NPI: 1780607754
Provider Name (Legal Business Name): PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 COLLEGE STREET
BLAKELY GA
39823
US

IV. Provider business mailing address

360 COLLEGE STREET
BLAKELY GA
39823
US

V. Phone/Fax

Practice location:
  • Phone: 229-723-2660
  • Fax: 229-723-2663
Mailing address:
  • Phone: 229-723-2660
  • Fax: 229-723-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN188412
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number057747
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number060068
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: MR. EDWIN V JAMES
Title or Position: CHIEF FINANCIAL OFFICER
Credential: BBA MBA
Phone: 229-723-2660