Provider Demographics
NPI:1124051040
Name:ARCHBOLD MEDICAL GROUP
Entity type:Organization
Organization Name:ARCHBOLD MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:HIGHTOWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-228-2853
Mailing Address - Street 1:900 CAIRO RD
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792
Mailing Address - Country:US
Mailing Address - Phone:229-227-5104
Mailing Address - Fax:229-227-5187
Practice Address - Street 1:555 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:FL
Practice Address - Zip Code:32344-2060
Practice Address - Country:US
Practice Address - Phone:850-997-2511
Practice Address - Fax:850-997-3022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0085940207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
10D0270322OtherCLIA
FL267978700Medicaid
FLK1215Medicare ID - Type Unspecified