Provider Demographics
NPI:1275542953
Name:DOUGLAS INTERNAL MEDICINE P.C.
Entity Type:Organization
Organization Name:DOUGLAS INTERNAL MEDICINE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-383-7826
Mailing Address - Street 1:306 WESTSIDE DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-3530
Mailing Address - Country:US
Mailing Address - Phone:912-383-7826
Mailing Address - Fax:912-383-7299
Practice Address - Street 1:306 WESTSIDE DR
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-3530
Practice Address - Country:US
Practice Address - Phone:912-383-7826
Practice Address - Fax:912-383-7299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7538Medicare PIN
GAREF000137448OtherMEDICAID REFERRAL NUMBER
GA85001593GMedicaid