=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023399813
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEADLEY FAMILY MEDICINE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2011
-----------------------------------------------------
Last Update Date | 10/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 S 1ST ST
-----------------------------------------------------
City | JESUP
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31545-0209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-427-7400
-----------------------------------------------------
Fax | 912-385-2953
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 606
-----------------------------------------------------
City | JESUP
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31598-0606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-427-7400
-----------------------------------------------------
Fax | 912-385-2953
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WILLIAM V HEADLEY JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 912-427-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 51471
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------