Provider Demographics
NPI:1033393723
Name:MILLEDGEVILLE FAMILLY PRACTICE CENTER P.C.
Entity Type:Organization
Organization Name:MILLEDGEVILLE FAMILLY PRACTICE CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRIMES
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:478-453-9435
Mailing Address - Street 1:540 W THOMAS ST STE B
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-2745
Mailing Address - Country:US
Mailing Address - Phone:478-453-9435
Mailing Address - Fax:478-453-9436
Practice Address - Street 1:540 W THOMAS ST STE B
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2745
Practice Address - Country:US
Practice Address - Phone:478-453-9435
Practice Address - Fax:478-453-9436
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MILLEDGEVILLE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA19830207Q00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00201517AMedicaid