MEDICARE: CLAY COUNTY COMMUNITY HEALTH CENTER, INC.

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1609364462
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLAY COUNTY COMMUNITY HEALTH CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 281
Second Line	:
City	:	FORT GAINES
State	:	GA
Zip	:	39851-0281
Country	:	US
Telephone Number	:	229-768-3888
Fax Number	:

Provider Business Practice Location Address
First Line	:	305 WASHINGTON ST S
Second Line	:
City	:	FORT GAINES
State	:	GA
Zip	:	39851-4315
Country	:	US
Telephone Number	:	229-768-3889
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT SPECIALIST
Name	:	STEPHANIE GILL
Credential	:
Telephone Number	:	470-233-0545

Provider Enumeration Date	:	04/27/2018
Last Update Date	:	04/27/2018

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