Basic Information
| Provider Information | |||||||||
| NPI: | 1902917040 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FLOYD HEALTHCARE MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FLOYD PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| 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: | 1008 N PIEDMONT AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKMART | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301532526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706847846 | ||||||||
| FaxNumber: | 7706848294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/20/2007 | ||||||||
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| 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 | 00000756D | 05 | GA | MEDICAID |