Healthcare Provider Details

I. General information

NPI: 1942312319
Provider Name (Legal Business Name): COLONY MEDICAL ASSOCIATES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 NORMAN DORMINY DR SUITE B
FITZGERALD GA
31750-8858
US

IV. Provider business mailing address

PO BOX 929
FITZGERALD GA
31750-0929
US

V. Phone/Fax

Practice location:
  • Phone: 229-423-2058
  • Fax: 229-423-0197
Mailing address:
  • Phone: 229-423-2058
  • Fax: 229-423-0197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN101986
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number33123
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number056020
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number053043
License Number StateGA

VIII. Authorized Official

Name: MRS. MYRA D GRIFFIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 229-423-2058