Basic Information
| Provider Information | |||||||||
| NPI: | 1962850396 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COLQUITT REGIONAL MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | GA SOUTH FAMILY MEDICINE RESIDENCY PROGRAM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1993 | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317761993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919131 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MAGNOLIA CT | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295029769 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2016 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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| AuthorizedOfficialLastName: | MERDIAN | ||||||||
| AuthorizedOfficialFirstName: | STEW | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF PHYSICIAN SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2298903531 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.