Healthcare Provider Details

I. General information

NPI: 1619541018
Provider Name (Legal Business Name): DMC PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 BENJAMIN H HILL DR SW
FITZGERALD GA
31750-8695
US

IV. Provider business mailing address

246 BENJAMIN H HILL DR SW
FITZGERALD GA
31750-8695
US

V. Phone/Fax

Practice location:
  • Phone: 229-409-0874
  • Fax:
Mailing address:
  • Phone: 229-409-0874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: PAIGE WYNN
Title or Position: CEO
Credential:
Phone: 229-424-7100