Provider Demographics
NPI:1154756369
Name:OCONEE PRIMARY CARE CENTER, LLC
Entity type:Organization
Organization Name:OCONEE PRIMARY CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JANELYN
Authorized Official - Middle Name:F
Authorized Official - Last Name:GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-468-4519
Mailing Address - Street 1:411 N COBB ST
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2634
Mailing Address - Country:US
Mailing Address - Phone:478-454-3470
Mailing Address - Fax:
Practice Address - Street 1:411 N COBB ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2634
Practice Address - Country:US
Practice Address - Phone:478-454-3470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-06
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140021AMedicaid
GA202G701823OtherMEDICARE PTAN