Basic Information
| Provider Information | |||||||||
| NPI: | 1497760243 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TMC TALLAPOOSA FAMILY HEALTHCARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 706 DIXIE ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388710 | ||||||||
| FaxNumber: | 7708125735 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 W LYON ST | ||||||||
| Address2: | |||||||||
| City: | TALLAPOOSA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301761288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708242800 | ||||||||
| FaxNumber: | 7708242810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7708388845 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 367607289B | 01 | GA | CLINIC RENDERING NUMBER | OTHER | 540960632A | 05 | GA | MEDICAID | CH7677 | 01 | GA | MEDICARE ID | OTHER |