Healthcare Provider Details

I. General information

NPI: 1114003779
Provider Name (Legal Business Name): VALDOSTA FAMILY MEDICINE ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2412 N OAK ST
VALDOSTA GA
31602-2567
US

IV. Provider business mailing address

2412 N OAK ST
VALDOSTA GA
31602-2567
US

V. Phone/Fax

Practice location:
  • Phone: 229-244-1400
  • Fax: 229-244-5512
Mailing address:
  • Phone: 229-244-1400
  • Fax: 229-244-5512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003072
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004849
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number004094
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN154901
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIRO02539
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number045725
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number029930
License Number StateGA
# 8
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number029951
License Number StateGA
# 9
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number030242
License Number StateGA
# 10
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number044001
License Number StateGA
# 11
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number041290
License Number StateGA
# 12
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number041978
License Number StateGA
# 13
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number008563
License Number StateGA

VIII. Authorized Official

Name: CRAIG E BISHOP
Title or Position: MANAGING PARTNER
Credential: D.O.
Phone: 229-244-1400