Basic Information
| Provider Information | |||||||||
| NPI: | 1346348133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOUSE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 S MADISON ST | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317925473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295207115 | ||||||||
| FaxNumber: | 2292360871 | ||||||||
| Practice Location | |||||||||
| Address1: | 9355 MAIN ST S | ||||||||
| Address2: | |||||||||
| City: | NAHUNTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 315536159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124626222 | ||||||||
| FaxNumber: | 9124626203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/02/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 011959 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 032781 | 01 | GA | BLUESHIELD | OTHER | 00038651A | 05 | GA | MEDICAID |