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General NPI Number Information
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NPI Number | 1710911458
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Entity Type | Organization
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Legal Business Name | MADISON PRIMARY CARE, LLC
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Dates
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Enumeration Date | 07/10/2006
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Last Update Date | 08/10/2007
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Provider Practice Location Address
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Address Line | 1820 BETHANY RD
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City | MADISON
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State | GA
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Zip | 30650-4701
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Country | US
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Telephone | 706-342-3103
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Fax | 706-342-7430
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Provider Business Mailing Address
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Address Line | 1820 BETHANY RD
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City | MADISON
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State | GA
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Zip | 30650-4701
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Country | US
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Telephone | 706-342-3103
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Fax | 706-342-7430
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Authorized Official
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Title or Position | CEO
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Name | TIMOTHY B GIBSON
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Credential | MD
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Telephone | 706-342-3103
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 015584
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License Number State | GA
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