Provider Demographics
NPI:1992102073
Name:PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Entity type:Organization
Organization Name:PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-723-2660
Mailing Address - Street 1:PO BOX 1479
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1479
Mailing Address - Country:US
Mailing Address - Phone:229-226-8800
Mailing Address - Fax:229-226-2036
Practice Address - Street 1:916 S BROAD ST
Practice Address - Street 2:UNIT B-2
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6113
Practice Address - Country:US
Practice Address - Phone:229-226-8800
Practice Address - Fax:229-226-2036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003155529AMedicaid