Provider Demographics
NPI:1104910520
Name:ARCHBOLD MEDICAL GROUP
Entity type:Organization
Organization Name:ARCHBOLD MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:HIGHTOWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-228-2853
Mailing Address - Street 1:704 S BROAD ST
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6107
Mailing Address - Country:US
Mailing Address - Phone:229-226-8880
Mailing Address - Fax:229-227-5370
Practice Address - Street 1:704 SOUTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6107
Practice Address - Country:US
Practice Address - Phone:229-226-8880
Practice Address - Fax:229-227-5370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA32907207T00000X
GA0411592081P2900X
GA368122084N0400X
GA535202084N0400X
GA20448207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700873Medicare PIN