Provider Demographics
NPI:1235340969
Name:FLINT RIVER MEDI CAL GROUP, LLC
Entity Type:Organization
Organization Name:FLINT RIVER MEDI CAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICE
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILP
Authorized Official - Middle Name:H
Authorized Official - Last Name:EASTMAN
Authorized Official - Suffix:III
Authorized Official - Credentials:CEO
Authorized Official - Phone:770-904-6731
Mailing Address - Street 1:509 SUMTER ST
Mailing Address - Street 2:
Mailing Address - City:MONTEZUMA
Mailing Address - State:GA
Mailing Address - Zip Code:31063-1733
Mailing Address - Country:US
Mailing Address - Phone:478-472-3100
Mailing Address - Fax:478-472-2412
Practice Address - Street 1:509 SUMTER ST
Practice Address - Street 2:
Practice Address - City:MONTEZUMA
Practice Address - State:GA
Practice Address - Zip Code:31063-1733
Practice Address - Country:US
Practice Address - Phone:478-472-3100
Practice Address - Fax:478-472-2412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6053Medicare Oscar/Certification