Provider Demographics
NPI:1457314999
Name:QUAIL RIDGE FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:QUAIL RIDGE FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:C
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:229-378-8110
Mailing Address - Street 1:1 DOCTORS PARK
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-3072
Mailing Address - Country:US
Mailing Address - Phone:229-378-8110
Mailing Address - Fax:229-378-8109
Practice Address - Street 1:1 DOCTORS PARK
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828
Practice Address - Country:US
Practice Address - Phone:229-378-8110
Practice Address - Fax:229-378-8109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA986982597AMedicaid
GA345982719AMedicaid
GA986982597AMedicaid