Healthcare Provider Details

I. General information

NPI: 1407375686
Provider Name (Legal Business Name): PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 09/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4681 US HIGHWAY 84 BYP W
THOMASVILLE GA
31792-2607
US

IV. Provider business mailing address

360 COLLEGE ST
BLAKELY GA
39823-2554
US

V. Phone/Fax

Practice location:
  • Phone: 229-227-2936
  • Fax: 229-225-5284
Mailing address:
  • Phone: 229-723-2660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: EDWIN JAMES
Title or Position: CFO
Credential:
Phone: 229-723-2660