Basic Information
Provider Information | |||||||||
NPI: | 1508801416 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TMC BUCHANAN FAMILY HEALTHCARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BUCHANAN MEDICAL CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 706 DIXIE ST STE 220 | ||||||||
Address2: |   | ||||||||
City: | CARROLLTON | ||||||||
State: | GA | ||||||||
PostalCode: | 301173819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7708388710 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2908 BUSINESS 27 | ||||||||
Address2: |   | ||||||||
City: | BUCHANAN | ||||||||
State: | GA | ||||||||
PostalCode: | 301134857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7706468281 | ||||||||
FaxNumber: | 7706463579 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/17/2006 | ||||||||
LastUpdateDate: | 11/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FOX | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
AuthorizedOfficialTelephone: | 7708128845 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 024466 | GA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.