Healthcare Provider Details

I. General information

NPI: 1548401060
Provider Name (Legal Business Name): OCMULGEE FAMILY MEDICINE LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2009
Last Update Date: 03/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 LEGION DR
EASTMAN GA
31023-6780
US

IV. Provider business mailing address

725 LEGION DR
EASTMAN GA
31023-6780
US

V. Phone/Fax

Practice location:
  • Phone: 478-374-3574
  • Fax:
Mailing address:
  • Phone: 478-374-3574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number031176
License Number StateGA

VIII. Authorized Official

Name: PATRICIA PATTERSON
Title or Position: M.D.
Credential:
Phone: 478-374-3574