Provider Demographics
NPI:1043384183
Name:SMITH & PURVIS FAMILY PRACTICE CLINIC, PC
Entity Type:Organization
Organization Name:SMITH & PURVIS FAMILY PRACTICE CLINIC, PC
Other - Org Name:STATESBORO FAMILY PRACTICE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL CODER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERI
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAIGNEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:912-764-1039
Mailing Address - Street 1:412 NORTHSIDE DR E
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4802
Mailing Address - Country:US
Mailing Address - Phone:912-764-9684
Mailing Address - Fax:912-489-8676
Practice Address - Street 1:412 NORTHSIDE DR E
Practice Address - Street 2:SUITE 200
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4802
Practice Address - Country:US
Practice Address - Phone:912-764-9684
Practice Address - Fax:912-489-8676
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA18745207Q00000X
GA029847207Q00000X
GA048703207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3719Medicare ID - Type Unspecified