Basic Information
| Provider Information | |||||||||
| NPI: | 1992147573 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOERUN FAMILY MEDICINE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 624 | ||||||||
| Address2: | |||||||||
| City: | DOERUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317440624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919131 | ||||||||
| FaxNumber: | 2298919079 | ||||||||
| Practice Location | |||||||||
| Address1: | 128 WEST BROAD AVE | ||||||||
| Address2: | |||||||||
| City: | DOERUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298919131 | ||||||||
| FaxNumber: | 2298919079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2013 | ||||||||
| LastUpdateDate: | 05/07/2015 | ||||||||
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| AuthorizedOfficialLastName: | SIMS | ||||||||
| AuthorizedOfficialFirstName: | WENDELL | ||||||||
| AuthorizedOfficialMiddleName: | LARRY | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2299853420 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | GA | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 11-8911 | 01 | GA | MEDICARE PART A | OTHER | 003157266A | 05 | GA | MEDICAID |