Basic Information
| Provider Information | |||||||||
| NPI: | 1902888357 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRVIN | ||||||||
| FirstName: | ELVIN | ||||||||
| MiddleName: | COY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 915 GORDON AVE | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317926614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292282000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 915 GORDON AVE | ||||||||
| Address2: | |||||||||
| City: | THOMASVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317926614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2292282000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 09/10/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME42445 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 33164 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 78392 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 041748300 | 05 | FL | MEDICAID | 17583 | 01 | FL | BLUE CROSS BLUE SHIELD OF FLORIDA | OTHER | 592-05580 | 01 | AL | BLUE CROSS BLUE SHIELD OF ALABAMA | OTHER | P00686500 | 01 | MEDICARE RAILROAD | OTHER |