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General NPI Number Information
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NPI Number | 1942312319
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Entity Type | Organization
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Legal Business Name | COLONY MEDICAL ASSOCIATES PC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 01/29/2014
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Provider Practice Location Address
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Address Line | 110 NORMAN DORMINY DR SUITE B
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City | FITZGERALD
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State | GA
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Zip | 31750-8858
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Country | US
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Telephone | 229-423-2058
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Fax | 229-423-0197
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Provider Business Mailing Address
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Address Line | PO BOX 929
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City | FITZGERALD
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State | GA
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Zip | 31750-0929
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Country | US
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Telephone | 229-423-2058
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Fax | 229-423-0197
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. MYRA D GRIFFIN
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Credential |
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Telephone | 229-423-2058
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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 | 056020
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 053043
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | RN101986
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 33123
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License Number State | GA
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