Provider Demographics
NPI:1245667021
Name:MACON COUNTY CONVENIENT CARE
Entity type:Organization
Organization Name:MACON COUNTY CONVENIENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:QUINCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-938-6439
Mailing Address - Street 1:512 SUMTER ST
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-1758
Mailing Address - Country:US
Mailing Address - Phone:404-938-6439
Mailing Address - Fax:
Practice Address - Street 1:512 SUMTER ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1758
Practice Address - Country:US
Practice Address - Phone:404-938-6439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-10
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000506437GMedicaid
GA000506437GMedicaid
GA08BBRMJMedicare PIN