Healthcare Provider Details

I. General information

NPI: 1861744179
Provider Name (Legal Business Name): COMMUNITY PRIMARY CARE OF GEORGIA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 10/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

343 PLANTATION WAY
MACON GA
31210-9286
US

IV. Provider business mailing address

4080 MCGINNIS FERRY RD SUITE 804
ALPHARETTA GA
30005-3948
US

V. Phone/Fax

Practice location:
  • Phone: 478-405-9000
  • Fax:
Mailing address:
  • Phone: 404-401-0225
  • 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: CHARLES KEMP
Title or Position: VICE PRESIDENT OF OPERATIONS
Credential:
Phone: 404-401-0225