Provider Demographics
NPI:1114962487
Name:WAYNE FAMILY PRACTICE ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:WAYNE FAMILY PRACTICE ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GWENELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:LIGHTSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-427-6964
Mailing Address - Street 1:PO BOX 937
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31598-0937
Mailing Address - Country:US
Mailing Address - Phone:912-427-6964
Mailing Address - Fax:912-427-0591
Practice Address - Street 1:330 PEACHTREE ST
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0244
Practice Address - Country:US
Practice Address - Phone:912-427-6964
Practice Address - Fax:912-427-0591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA85001314GMedicaid
GAGRP1518Medicare ID - Type Unspecified