Provider Demographics
NPI:1194835280
Name:EAST GEORGIA INTERNAL MEDICINE ,LLC
Entity Type:Organization
Organization Name:EAST GEORGIA INTERNAL MEDICINE ,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:OLADAPO
Authorized Official - Middle Name:O
Authorized Official - Last Name:FAWIBE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-736-4154
Mailing Address - Street 1:PO BOX 3407
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3407
Mailing Address - Country:US
Mailing Address - Phone:706-736-4154
Mailing Address - Fax:706-736-4155
Practice Address - Street 1:811 13TH ST
Practice Address - Street 2:SUITE 11
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2700
Practice Address - Country:US
Practice Address - Phone:706-736-4154
Practice Address - Fax:706-736-4155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty