=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740440080
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CARE OF NORTHWEST GEORGIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2008
-----------------------------------------------------
Last Update Date | 06/10/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 204 N DUKE ST
-----------------------------------------------------
City | LA FAYETTE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30728-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-639-9055
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 606
-----------------------------------------------------
City | LA FAYETTE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30728-0606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RALPH EDWARD BOWERS II
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 706-397-2007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------