Provider Demographics
NPI:1699274167
Name:ADVANCED MEDICAL GROUP LLC
Entity type:Organization
Organization Name:ADVANCED MEDICAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAWLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-689-2389
Mailing Address - Street 1:PO BOX 1860
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29834-1860
Mailing Address - Country:US
Mailing Address - Phone:706-547-2225
Mailing Address - Fax:888-273-1488
Practice Address - Street 1:206 E BROAD ST
Practice Address - Street 2:
Practice Address - City:WRENS
Practice Address - State:GA
Practice Address - Zip Code:30833-1109
Practice Address - Country:US
Practice Address - Phone:706-547-2225
Practice Address - Fax:706-547-3012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-09
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
GAPHRE0104303336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA744933579AMedicaid
2175805OtherPK