Provider Demographics
NPI:1992147573
Name:DOERUN FAMILY MEDICINE CLINIC
Entity type:Organization
Organization Name:DOERUN FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-985-3420
Mailing Address - Street 1:PO BOX 624
Mailing Address - Street 2:
Mailing Address - City:DOERUN
Mailing Address - State:GA
Mailing Address - Zip Code:31744-0624
Mailing Address - Country:US
Mailing Address - Phone:229-891-9131
Mailing Address - Fax:229-891-9079
Practice Address - Street 1:128 WEST BROAD AVE
Practice Address - Street 2:
Practice Address - City:DOERUN
Practice Address - State:GA
Practice Address - Zip Code:31744
Practice Address - Country:US
Practice Address - Phone:229-891-9131
Practice Address - Fax:229-891-9079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11-8911OtherMEDICARE PART A
GA003157266AMedicaid