Healthcare Provider Details

I. General information

NPI: 1336492511
Provider Name (Legal Business Name): COMMUNITY PRIMARY CARE OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2012
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 BOULDER DR
GRAY GA
31032-6141
US

IV. Provider business mailing address

1005 BOULDER DR
GRAY GA
31032-6141
US

V. Phone/Fax

Practice location:
  • Phone: 478-621-2100
  • Fax: 478-744-0481
Mailing address:
  • Phone: 478-621-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: ELIZE JOSEPH
Title or Position: DIRECTOR OF PRACTICE MANAGEMENT
Credential:
Phone: 478-621-2100