Provider Demographics
NPI:1407375686
Name:PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Entity Type:Organization
Organization Name:PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Other - Org Name:PRIMARY CARE OF SOUTHWEST GEORGIA-TCMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-723-2660
Mailing Address - Street 1:360 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-2554
Mailing Address - Country:US
Mailing Address - Phone:229-723-2660
Mailing Address - Fax:
Practice Address - Street 1:4681 US HIGHWAY 84 BYP W
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-2607
Practice Address - Country:US
Practice Address - Phone:229-227-2936
Practice Address - Fax:229-225-5284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)