Provider Demographics
NPI:1992153548
Name:HOMETOWN PHYSICIAN GROUP, LLC
Entity type:Organization
Organization Name:HOMETOWN PHYSICIAN GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:TERRELL
Authorized Official - Last Name:ALFORD
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:706-594-1598
Mailing Address - Street 1:300 MOOTY BRIDGE RD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-1881
Mailing Address - Country:US
Mailing Address - Phone:706-523-1699
Mailing Address - Fax:
Practice Address - Street 1:1698 VERNON RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4100
Practice Address - Country:US
Practice Address - Phone:706-298-4937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty