Provider Demographics
NPI:1144552423
Name:IMMEDIATE CARE OF ROME #1, LLC
Entity type:Organization
Organization Name:IMMEDIATE CARE OF ROME #1, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-354-1036
Mailing Address - Street 1:18 RIVERBEND DR SW
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6013
Mailing Address - Country:US
Mailing Address - Phone:706-291-2999
Mailing Address - Fax:706-291-4006
Practice Address - Street 1:18 RIVERBEND DR SW
Practice Address - Street 2:SUITE 230
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6013
Practice Address - Country:US
Practice Address - Phone:706-291-2999
Practice Address - Fax:706-291-4006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN113917363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty