Provider Demographics
NPI:1083769376
Name:DOUGLAS COUNTY FAMILY PRACTICE, P.C.
Entity Type:Organization
Organization Name:DOUGLAS COUNTY FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-949-5535
Mailing Address - Street 1:3872 HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-3366
Mailing Address - Country:US
Mailing Address - Phone:770-949-5535
Mailing Address - Fax:770-949-9022
Practice Address - Street 1:3872 HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-3366
Practice Address - Country:US
Practice Address - Phone:770-949-5535
Practice Address - Fax:770-949-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X
GA023734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA442225907AMedicaid
GA085111111GMedicaid
GA1972590982OtherNPI-DR. MARIAM GEORGE
GA023734OtherLICENSE#DR. MARIAM GEORGE
GAD45421Medicare UPIN
GA023734OtherLICENSE#DR. MARIAM GEORGE
GA1972590982OtherNPI-DR. MARIAM GEORGE
GA58307OtherLICENSE#DR. HARNISH PATEL
GAD45421Medicare UPIN
GAI08046Medicare UPIN