Provider Demographics
NPI:1033314711
Name:WHEELER COUNTY FAMILY MEDICINE
Entity Type:Organization
Organization Name:WHEELER COUNTY FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ODELL
Authorized Official - Middle Name:P
Authorized Official - Last Name:STILL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:912-537-0616
Mailing Address - Street 1:104 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30474-8949
Mailing Address - Country:US
Mailing Address - Phone:912-537-0616
Mailing Address - Fax:912-537-0617
Practice Address - Street 1:104 MAPLE DR
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8949
Practice Address - Country:US
Practice Address - Phone:912-537-0616
Practice Address - Fax:912-537-0617
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-20
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037085207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000347751CMedicaid
GA000539624EMedicaid
GA000539624KMedicaid
GA000631474AMedicaid
GA393478520AMedicaid
GA000954533CMedicaid
GA644701462AMedicaid
GA091222821AMedicaid
GA000954533CMedicaid
GA644701462AMedicaid