Provider Demographics
NPI:1063566909
Name:COLUMBUS PRIMARY CARE INTERNAL MEDICINE PC
Entity type:Organization
Organization Name:COLUMBUS PRIMARY CARE INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDET
Authorized Official - Middle Name:O
Authorized Official - Last Name:BASSEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-660-8825
Mailing Address - Street 1:PO BOX 2746
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-2746
Mailing Address - Country:US
Mailing Address - Phone:706-660-8825
Mailing Address - Fax:706-660-8897
Practice Address - Street 1:1041 TALBOTTON RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8745
Practice Address - Country:US
Practice Address - Phone:706-660-8825
Practice Address - Fax:706-660-8897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044408207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000807881CMedicaid
GA00807881CMedicaid
GA11BDTXWMedicare ID - Type Unspecified
GA00807881CMedicaid