Healthcare Provider Details

I. General information

NPI: 1295905073
Provider Name (Legal Business Name): CARON MEDICAL CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2008
Last Update Date: 03/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11638 HIGHWAY 27 SUITE 8
SUMMERVILLE GA
30747-8514
US

IV. Provider business mailing address

11638 HIGHWAY 27 SUITE 8
SUMMERVILLE GA
30747-8514
US

V. Phone/Fax

Practice location:
  • Phone: 706-857-2133
  • Fax: 706-857-2139
Mailing address:
  • Phone: 706-857-2133
  • Fax: 706-857-2139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number046377
License Number StateGA

VIII. Authorized Official

Name: DR. DOUGLAS E CARON
Title or Position: PRESIDENT
Credential: MD
Phone: 706-857-2133