MEDICARE: CARTERSVILLE FAMILY MEDICINE, 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	207Q00000X	Family Medicine Physician	0101222830	VA
2	207Q00000X	Family Medicine Physician	0024129303	VA

General Provider Information

NPI Number	:	1962460659
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARTERSVILLE FAMILY MEDICINE, INC.

Provider Business Mailing Address
First Line	:	2294 CARTERSVILLE RD
Second Line	:
City	:	CARTERSVILLE
State	:	VA
Zip	:	23027-9701
Country	:	US
Telephone Number	:	804-375-9180
Fax Number	:	804-375-9297

Provider Business Practice Location Address
First Line	:	2294 CARTERSVILLE RD
Second Line	:
City	:	CARTERSVILLE
State	:	VA
Zip	:	23027-9701
Country	:	US
Telephone Number	:	804-375-9180
Fax Number	:	804-375-9297

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. JO MYERS WILSON
Credential	:	M.D.
Telephone Number	:	804-375-9180

Provider Enumeration Date	:	05/02/2006
Last Update Date	:	08/22/2020

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