Provider Demographics
NPI:1134164452
Name:SATILLA FAMILY MEDICINE, P.C.
Entity type:Organization
Organization Name:SATILLA FAMILY MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:MUKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:AGARWAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-338-0065
Mailing Address - Street 1:407 W ONEIDA ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-5320
Mailing Address - Country:US
Mailing Address - Phone:912-338-0065
Mailing Address - Fax:912-338-0920
Practice Address - Street 1:407 W ONEIDA ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-5320
Practice Address - Country:US
Practice Address - Phone:912-338-0065
Practice Address - Fax:912-338-0920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048327207Q00000X
GA039994207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA085002995GMedicaid
GA085002995GMedicaid