Provider Demographics
NPI:1306987235
Name:EVANS URGENT CARE
Entity type:Organization
Organization Name:EVANS URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-364-5500
Mailing Address - Street 1:PO BOX 2628
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-2628
Mailing Address - Country:US
Mailing Address - Phone:706-364-5500
Mailing Address - Fax:706-364-6863
Practice Address - Street 1:800 OAKHURST DR
Practice Address - Street 2:
Practice Address - City:EVANS
Practice Address - State:GA
Practice Address - Zip Code:30809-3650
Practice Address - Country:US
Practice Address - Phone:706-364-5500
Practice Address - Fax:706-364-6863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046334207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA4524Medicare ID - Type UnspecifiedMEDICARE GROUP
GA08BBWRQMedicare PIN
GAH53396Medicare UPIN