Provider Demographics
NPI:1083253140
Name:INTERCARE MEDICAL, CORP
Entity Type:Organization
Organization Name:INTERCARE MEDICAL, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:C
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-432-1111
Mailing Address - Street 1:62 CONIFER CIR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4506
Mailing Address - Country:US
Mailing Address - Phone:706-465-6260
Mailing Address - Fax:
Practice Address - Street 1:3540 WHEELER RD STE 307
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1887
Practice Address - Country:US
Practice Address - Phone:706-432-1111
Practice Address - Fax:706-945-0638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain