Basic Information
| Provider Information | |||||||||
| NPI: | 1124433768 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TOTAL CARE FAMILY MEDICINE PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TOTAL CARE FAMILY MEDICINE TEMPLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2022 FAIRBURN RD | ||||||||
| Address2: | SUITE D | ||||||||
| City: | DOUGLASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301351062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7709421699 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 CARROLLTON ST | ||||||||
| Address2: | |||||||||
| City: | TEMPLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301793796 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709421044 | ||||||||
| FaxNumber: | 7709421699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2014 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BURTON | ||||||||
| AuthorizedOfficialFirstName: | KELVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7709421044 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TOTAL CARE FAMILY MEDICINE PC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 032101 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.