Healthcare Provider Details

I. General information

NPI: 1225551328
Provider Name (Legal Business Name): SOUTHERN PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 01/21/2024
Certification Date: 01/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 BASS RD
MACON GA
31210-2060
US

IV. Provider business mailing address

197 BASS RD
MACON GA
31210-2060
US

V. Phone/Fax

Practice location:
  • Phone: 478-365-2164
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAYESH D PATEL
Title or Position: BUSINESS OWNER
Credential: MD
Phone: 478-365-2164