Provider Demographics
NPI:1104025717
Name:MEDICAL CENTER FAMILY PRACTICE
Entity Type:Organization
Organization Name:MEDICAL CENTER FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-335-5155
Mailing Address - Street 1:45 MEDICAL CENTER CT
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-1085
Mailing Address - Country:US
Mailing Address - Phone:706-335-5155
Mailing Address - Fax:706-335-5256
Practice Address - Street 1:45 MEDICAL CENTER CT
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-1085
Practice Address - Country:US
Practice Address - Phone:706-335-5155
Practice Address - Fax:706-335-5256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030139207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00410484AMedicaid
GAD46015OtherUPIN
GA08BDBLQMedicare PIN