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General NPI Number Information
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NPI Number | 1205078979
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Entity Type | Organization
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Legal Business Name | VIDALIA FAMILY HEALTH CLINIC LLC
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Dates
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Enumeration Date | 03/27/2009
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Last Update Date | 03/27/2009
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Provider Practice Location Address
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Address Line | 1811 MANNING DR
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City | VIDALIA
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State | GA
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Zip | 30474-8921
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Country | US
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Telephone | 912-537-7674
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Fax | 912-538-8443
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Provider Business Mailing Address
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Address Line | 1811 MANNING DR
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City | VIDALIA
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State | GA
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Zip | 30474-8921
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Country | US
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Telephone | 912-537-7674
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Fax | 912-538-8443
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Authorized Official
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Title or Position | PHYSICIAN
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Name | MR. THOMAS FERRARI
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Credential | M.D.
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Telephone | 912-537-7476
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | GA034829
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License Number State | GA
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