Provider Demographics
NPI:1699937011
Name:COLQUITT REGIONAL MED CARE CLINIC
Entity type:Organization
Organization Name:COLQUITT REGIONAL MED CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:LOWRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-985-3420
Mailing Address - Street 1:633 VETERANS PKWY S
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31788-8811
Mailing Address - Country:US
Mailing Address - Phone:229-890-7009
Mailing Address - Fax:
Practice Address - Street 1:633 VETERANS PKWY S
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31788-8811
Practice Address - Country:US
Practice Address - Phone:229-890-7009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLQUITT REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035-296261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA388946OtherWELLCARE OF GEORGIA