Healthcare Provider Details

I. General information

NPI: 1083769376
Provider Name (Legal Business Name): DOUGLAS COUNTY FAMILY PRACTICE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 02/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3872 HIGHWAY 5
DOUGLASVILLE GA
30135-3366
US

IV. Provider business mailing address

3872 HIGHWAY 5
DOUGLASVILLE GA
30135-3366
US

V. Phone/Fax

Practice location:
  • Phone: 770-949-5535
  • Fax: 770-949-9022
Mailing address:
  • Phone: 770-949-5535
  • Fax: 770-949-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARIAM GEORGE
Title or Position: PRACTICE ADMINISTRATOR
Credential: MD
Phone: 770-949-5535