=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770521460
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INPHYNET PRIMARY CARE PHYSICIANS SOUTHEAST PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2006
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2122 MANCHESTER EXPY
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31904-6878
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-596-4000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 636017
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45263-6017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-424-3672
-----------------------------------------------------
Fax | 954-377-3042
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER ENROLLMENT DIRECTOR
-----------------------------------------------------
Name | TONYA LYNN SCANLAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-377-2954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------