Provider Demographics
NPI:1235703638
Name:DMC PHYSICIAN GROUP LLC
Entity Type:Organization
Organization Name:DMC PHYSICIAN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAIGE
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-424-7100
Mailing Address - Street 1:200 PERRY HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-8857
Mailing Address - Country:US
Mailing Address - Phone:229-424-7100
Mailing Address - Fax:
Practice Address - Street 1:613 S GRANT ST
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-3315
Practice Address - Country:US
Practice Address - Phone:229-424-0134
Practice Address - Fax:229-424-7390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty