Provider Demographics
NPI:1114956075
Name:SOUTHCARE MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTHCARE MEDICAL CENTER
Other - Org Name:AR MEDICAL LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FIROZ
Authorized Official - Middle Name:
Authorized Official - Last Name:PATKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-625-7597
Mailing Address - Street 1:2514 TOBACCO RD STE C
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-7005
Mailing Address - Country:US
Mailing Address - Phone:706-790-0311
Mailing Address - Fax:706-790-0815
Practice Address - Street 1:809 PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:GA
Practice Address - Zip Code:30434-1449
Practice Address - Country:US
Practice Address - Phone:478-625-7597
Practice Address - Fax:478-625-8364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAC56117Medicare UPIN
GA97WCGCVMedicare ID - Type UnspecifiedPATRICK WALTERS PA
GAQ3028Medicare UPIN
GA11BDWLKMedicare ID - Type UnspecifiedFIROZ PATKA MD