Healthcare Provider Details

I. General information

NPI: 1457314999
Provider Name (Legal Business Name): QUAIL RIDGE FAMILY PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 DOCTORS PARK
CAIRO GA
39828
US

IV. Provider business mailing address

1 DOCTORS PARK
CAIRO GA
39828-3072
US

V. Phone/Fax

Practice location:
  • Phone: 229-378-8110
  • Fax: 229-378-8109
Mailing address:
  • Phone: 229-378-8110
  • Fax: 229-378-8109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARK C HUDSON
Title or Position: OWNER
Credential: D.O.
Phone: 229-378-8110