Provider Demographics
NPI:1770521460
Name:INPHYNET PRIMARY CARE PHYSICIANS SOUTHEAST PC
Entity type:Organization
Organization Name:INPHYNET PRIMARY CARE PHYSICIANS SOUTHEAST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SCANLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-377-2954
Mailing Address - Street 1:PO BOX 636017
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6017
Mailing Address - Country:US
Mailing Address - Phone:800-424-3672
Mailing Address - Fax:954-377-3042
Practice Address - Street 1:2122 MANCHESTER EXPY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6878
Practice Address - Country:US
Practice Address - Phone:706-596-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL179928Medicaid
GA300041815AMedicaid
AL529601690Medicaid
GA169393100OtherUS DEPT OF LABOR
GACG3225OtherMEDICARE TRAVELERS RR - G