MEDICARE: FAMILY MEDICAL ASSOCIATES OF LAKE OCONEE PC

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	207Q00000X	Family Medicine Physician	30368	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790861581
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY MEDICAL ASSOCIATES OF LAKE OCONEE PC

Provider Business Mailing Address
First Line	:	1041 PARK DR
Second Line	:
City	:	GREENSBORO
State	:	GA
Zip	:	30642-3465
Country	:	US
Telephone Number	:	706-453-4945
Fax Number	:

Provider Business Practice Location Address
First Line	:	1041 PARK DR
Second Line	:
City	:	GREENSBORO
State	:	GA
Zip	:	30642-3465
Country	:	US
Telephone Number	:	706-453-4945
Fax Number	:

Authorized Official
Title or Position	:	CIO
Name	:	TEENA R LONG
Credential	:
Telephone Number	:	706-319-8762

Provider Enumeration Date	:	10/27/2006
Last Update Date	:	05/24/2013

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