Provider Demographics
NPI:1073775904
Name:SUMTER FAMILY MEDICINE & SPORTS MEDICINE CENTER, P.C.
Entity Type:Organization
Organization Name:SUMTER FAMILY MEDICINE & SPORTS MEDICINE CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:BUSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-924-2383
Mailing Address - Street 1:PO BOX 6815
Mailing Address - Street 2:
Mailing Address - City:AMERICUS
Mailing Address - State:GA
Mailing Address - Zip Code:31709-6815
Mailing Address - Country:US
Mailing Address - Phone:229-924-2383
Mailing Address - Fax:229-924-0684
Practice Address - Street 1:922 E JEFFERSON ST
Practice Address - Street 2:SUITE B
Practice Address - City:AMERICUS
Practice Address - State:GA
Practice Address - Zip Code:31709-4780
Practice Address - Country:US
Practice Address - Phone:229-924-2383
Practice Address - Fax:229-924-0684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040628207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000720893DMedicaid
GA11SCDHGMedicare PIN
GA000720893DMedicaid