Provider Demographics
NPI:1538427570
Name:UNITED PHYSICIANS OF GEORGIA, LLC
Entity type:Organization
Organization Name:UNITED PHYSICIANS OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DWAYNE
Authorized Official - Middle Name:D
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-812-5988
Mailing Address - Street 1:101 RICE BENT WAY
Mailing Address - Street 2:SUITE 12
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-6849
Mailing Address - Country:US
Mailing Address - Phone:803-807-9533
Mailing Address - Fax:877-903-1383
Practice Address - Street 1:7335 OLD NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-1607
Practice Address - Country:US
Practice Address - Phone:803-807-9533
Practice Address - Fax:877-903-1383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty