Provider Demographics
NPI:1285064931
Name:SJ &J MEDICAL GROUP AND URGENT CARE
Entity type:Organization
Organization Name:SJ &J MEDICAL GROUP AND URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:706-593-7766
Mailing Address - Street 1:304 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2746
Mailing Address - Country:US
Mailing Address - Phone:706-882-0382
Mailing Address - Fax:
Practice Address - Street 1:304 SMITH ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2746
Practice Address - Country:US
Practice Address - Phone:706-882-0382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-16
Last Update Date:2013-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN154861NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
20250I3642OtherMEDICARE-PTAN