Healthcare Provider Details

I. General information

NPI: 1861915647
Provider Name (Legal Business Name): 316 FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 GORDON ST
BREMEN GA
30110-1519
US

IV. Provider business mailing address

PO BOX 728
BREMEN GA
30110-0728
US

V. Phone/Fax

Practice location:
  • Phone: 770-537-1234
  • Fax: 770-537-1237
Mailing address:
  • Phone: 770-537-1234
  • Fax: 770-537-1235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number059986
License Number StateGA

VIII. Authorized Official

Name: NOELLE SMITH
Title or Position: PRACTICE MANAGER
Credential:
Phone: 770-634-8905