Healthcare Provider Details

I. General information

NPI: 1992102073
Provider Name (Legal Business Name): PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 04/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 S BROAD ST UNIT B-2
THOMASVILLE GA
31792-6113
US

IV. Provider business mailing address

PO BOX 1479
THOMASVILLE GA
31799-1479
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-8800
  • Fax: 229-226-2036
Mailing address:
  • Phone: 229-226-8800
  • Fax: 229-226-2036

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