Provider Demographics
NPI:1093472896
Name:ALTAMAHA PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:ALTAMAHA PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:AGACNP, RN
Authorized Official - Phone:912-559-2420
Mailing Address - Street 1:248 NE BROAD ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31546-4371
Mailing Address - Country:US
Mailing Address - Phone:912-559-2696
Mailing Address - Fax:912-559-2420
Practice Address - Street 1:248 NE BROAD ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31546-4371
Practice Address - Country:US
Practice Address - Phone:912-559-2696
Practice Address - Fax:912-559-2420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-29
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG07348BMedicaid