Provider Demographics
NPI:1023007424
Name:REDMOND PHYSICIAN PRACTICE COMPANY
Entity Type:Organization
Organization Name:REDMOND PHYSICIAN PRACTICE COMPANY
Other - Org Name:REDMOND FAMILY CARE CENTER AT EAST ROME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7604
Mailing Address - Street 1:715 E 2ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-6148
Mailing Address - Country:US
Mailing Address - Phone:706-235-1102
Mailing Address - Fax:706-235-7188
Practice Address - Street 1:715 E 2ND AVE SW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-6148
Practice Address - Country:US
Practice Address - Phone:706-235-1102
Practice Address - Fax:706-235-7188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2870Medicare PIN
CB6391Medicare PIN