Healthcare Provider Details

I. General information

NPI: 1346348133
Provider Name (Legal Business Name): JOHN C HOUSE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9355 MAIN ST S
NAHUNTA GA
31553-6159
US

IV. Provider business mailing address

100 S MADISON ST
THOMASVILLE GA
31792-5473
US

V. Phone/Fax

Practice location:
  • Phone: 912-462-6222
  • Fax: 912-462-6203
Mailing address:
  • Phone: 229-520-7115
  • Fax: 229-236-0871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number011959
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier032781
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerBLUESHIELD
# 2
Identifier00038651A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: