Provider Demographics
NPI:1366847790
Name:FASTTRACK IMMEDIATE CARE OF MILLEDGEVILLE LLC
Entity Type:Organization
Organization Name:FASTTRACK IMMEDIATE CARE OF MILLEDGEVILLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:NOBLES
Authorized Official - Last Name:PAULK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-271-0337
Mailing Address - Street 1:126 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014-6330
Mailing Address - Country:US
Mailing Address - Phone:478-271-0337
Mailing Address - Fax:478-295-3003
Practice Address - Street 1:1909 N COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2170
Practice Address - Country:US
Practice Address - Phone:478-295-3000
Practice Address - Fax:478-295-3003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========Other=========