Provider Demographics
NPI:1730354739
Name:AIRPORT CLINIC INC
Entity type:Organization
Organization Name:AIRPORT CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-242-9003
Mailing Address - Street 1:704 GIL HARBIN INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601-6513
Mailing Address - Country:US
Mailing Address - Phone:229-242-9003
Mailing Address - Fax:
Practice Address - Street 1:704 GIL HARBIN INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601-6513
Practice Address - Country:US
Practice Address - Phone:229-242-9003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA227527287BMedicaid
GA227527287BMedicaid