Provider Demographics
NPI:1972725216
Name:FAMILY PRACTICE ASSOICATES LLC
Entity type:Organization
Organization Name:FAMILY PRACTICE ASSOICATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER/PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:229-391-3300
Mailing Address - Street 1:612 LOVE AVE
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794
Mailing Address - Country:US
Mailing Address - Phone:229-391-3300
Mailing Address - Fax:229-388-1948
Practice Address - Street 1:612 LOVE AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794
Practice Address - Country:US
Practice Address - Phone:229-391-3300
Practice Address - Fax:229-388-1948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28796208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA85002772GMedicaid
GA85002772GMedicaid