MEDICARE: GEORGIA PRIMARY CARE 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	363LP2300X	Primary Care Nurse Practitioner
2	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1548025596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEORGIA PRIMARY CARE LLC

Provider Business Mailing Address
First Line	:	866 ORANGE TER
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31201-2151
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	866 ORANGE TER
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31201-2151
Country	:	US
Telephone Number	:	478-246-1114
Fax Number	:	478-202-2488

Authorized Official
Title or Position	:	OWNER
Name	:	LARRY A MONTGOMERY
Credential	:	NURSE PRACTITIONER
Telephone Number	:	918-340-6477

Provider Enumeration Date	:	02/19/2024
Last Update Date	:	05/28/2026

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