Healthcare Provider Details

I. General information

NPI: 1548025596
Provider Name (Legal Business Name): GEORGIA PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2024
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

866 ORANGE TER
MACON GA
31201-2151
US

IV. Provider business mailing address

866 ORANGE TER
MACON GA
31201-2151
US

V. Phone/Fax

Practice location:
  • Phone: 478-246-1114
  • Fax: 478-202-2488
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LARRY A MONTGOMERY
Title or Position: OWNER
Credential: NURSE PRACTITIONER
Phone: 918-340-6477