Provider Demographics
NPI:1780607754
Name:PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
Entity type:Organization
Organization Name:PRIMARY CARE OF SOUTHWEST GEORGIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:V
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:BBA MBA
Authorized Official - Phone:229-723-2660
Mailing Address - Street 1:360 COLLEGE STREET
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823
Mailing Address - Country:US
Mailing Address - Phone:229-723-2660
Mailing Address - Fax:229-723-2663
Practice Address - Street 1:360 COLLEGE STREET
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823
Practice Address - Country:US
Practice Address - Phone:229-723-2660
Practice Address - Fax:229-723-2663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN188412363LF0000X
GA057747207R00000X
GA060068207Q00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA024893266AMedicaid
GA111893Medicare Oscar/Certification
GRP7568Medicare PIN