Basic Information
| Provider Information | |||||||||
| NPI: | 1770521460 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INPHYNET PRIMARY CARE PHYSICIANS SOUTHEAST PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 636017 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452636017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004243672 | ||||||||
| FaxNumber: | 9543773042 | ||||||||
| Practice Location | |||||||||
| Address1: | 2122 MANCHESTER EXPY | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 319046878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065964000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 09/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | WHITE | ||||||||
| AuthorizedOfficialFirstName: | TONYA | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9543772954 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 169393100 | 01 | GA | US DEPT OF LABOR | OTHER | CG3225 | 01 | GA | MEDICARE TRAVELERS RR - G | OTHER | 300041815A | 05 | GA | MEDICAID | 179928 | 05 | AL | MEDICAID | 529601690 | 05 | AL | MEDICAID |