Healthcare Provider Details

I. General information

NPI: 1124430020
Provider Name (Legal Business Name): DMC PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2014
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PERRY HOUSE RD
FITZGERALD GA
31750-8857
US

IV. Provider business mailing address

200 PERRY HOUSE RD
FITZGERALD GA
31750-8857
US

V. Phone/Fax

Practice location:
  • Phone: 229-424-7260
  • Fax:
Mailing address:
  • Phone: 229-424-7260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code282NR1301X
TaxonomyRural Acute Care Hospital
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: MRS. PAIGE WYNN
Title or Position: INTERIM CEO
Credential:
Phone: 478-289-1376