MEDICARE: PATRIOT HEALTHCARE OF GEORGIA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QG0300X	Geriatric Medicine (Family Medicine) Physician

General Provider Information

NPI Number	:	1275002636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PATRIOT HEALTHCARE OF GEORGIA, LLC

Provider Business Mailing Address
First Line	:	100 ARRICOLA AVENUE
Second Line	:
City	:	ST. AUGUSTINE
State	:	FL
Zip	:	32080
Country	:	US
Telephone Number	:	904-825-4368
Fax Number	:

Provider Business Practice Location Address
First Line	:	1587 PHOENIX BOULEVARD
Second Line	:	SUITE 6
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349
Country	:	US
Telephone Number	:	404-435-6029
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DAVID A. CULVER
Credential	:
Telephone Number	:	904-825-4368

Provider Enumeration Date	:	11/15/2018
Last Update Date	:	11/15/2018

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