Basic Information
Provider Information | |||||||||
NPI: | 1710098850 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FLOYD HEALTHCARE MANAGEMENT, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FLOYD PRIMARY CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 420 E 2ND AVE | ||||||||
Address2: | SUITE 103 | ||||||||
City: | ROME | ||||||||
State: | GA | ||||||||
PostalCode: | 301613224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7065093278 | ||||||||
FaxNumber: | 7065094608 | ||||||||
Practice Location | |||||||||
Address1: | 6000 JOE FRANK HARRIS PKWY NW | ||||||||
Address2: |   | ||||||||
City: | ADAIRSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 301032443 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7707739448 | ||||||||
FaxNumber: | 7707731534 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 12/20/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUSSELL | ||||||||
AuthorizedOfficialFirstName: | DEE | ||||||||
AuthorizedOfficialMiddleName: | B. | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE VICE PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7065093278 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FLOYD HEALTHCARE MANAGEMENT, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center |   |
ID Information
ID | Type | State | Issuer | Description | 00000756G | 05 | GA |   | MEDICAID |