Basic Information
| Provider Information | |||||||||
| NPI: | 1366602153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIN | ||||||||
| FirstName: | JAMIE | ||||||||
| MiddleName: | O | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E 2ND AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301613209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065093000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 123 THREE RIVERS DR NE | ||||||||
| Address2: | |||||||||
| City: | ROME | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301612300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062953961 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2008 | ||||||||
| LastUpdateDate: | 06/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 062389 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 062389 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 259849458C | 05 | GA | MEDICAID |