Healthcare Provider Details

I. General information

NPI: 1770521460
Provider Name (Legal Business Name): INPHYNET PRIMARY CARE PHYSICIANS SOUTHEAST PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2122 MANCHESTER EXPY
COLUMBUS GA
31904-6878
US

IV. Provider business mailing address

PO BOX 636017
CINCINNATI OH
45263-6017
US

V. Phone/Fax

Practice location:
  • Phone: 706-596-4000
  • Fax:
Mailing address:
  • Phone: 800-424-3672
  • Fax: 954-377-3042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: TONYA LYNN SCANLAN
Title or Position: PROVIDER ENROLLMENT DIRECTOR
Credential:
Phone: 954-377-2954