Provider Demographics
NPI:1053627703
Name:NEOCARE OF CENTRAL GEORGIA, PC
Entity Type:Organization
Organization Name:NEOCARE OF CENTRAL GEORGIA, PC
Other - Org Name:FAMILY CARE OF MIDDLE GEORGIA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:HO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C, MBA
Authorized Official - Phone:478-471-0273
Mailing Address - Street 1:3203 VINEVILLE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-2323
Mailing Address - Country:US
Mailing Address - Phone:478-471-0273
Mailing Address - Fax:478-471-1471
Practice Address - Street 1:3203 VINEVILLE AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-2323
Practice Address - Country:US
Practice Address - Phone:478-471-0273
Practice Address - Fax:478-471-1471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA076861207Q00000X
208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000053347CMedicaid
GA000262996IMedicaid
GA003171965EMedicaid
GA003121342GMedicaid
GA003177670CMedicaid
GA000262996HMedicaid
GA000053347DMedicaid
GA003171965FMedicaid
GA003177670BMedicaid
GA003171965DMedicaid
GA003177670AMedicaid
GA000053347EMedicaid