Provider Demographics
NPI:1275002636
Name:PATRIOT HEALTHCARE OF GEORGIA, LLC
Entity Type:Organization
Organization Name:PATRIOT HEALTHCARE OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:CULVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-825-4368
Mailing Address - Street 1:100 ARRICOLA AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST. AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080
Mailing Address - Country:US
Mailing Address - Phone:904-825-4368
Mailing Address - Fax:
Practice Address - Street 1:1587 PHOENIX BOULEVARD
Practice Address - Street 2:SUITE 6
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349
Practice Address - Country:US
Practice Address - Phone:404-435-6029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty