Provider Demographics
NPI:1477239218
Name:BULLOCH FAMILY PRACTICE
Entity Type:Organization
Organization Name:BULLOCH FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LOY
Authorized Official - Middle Name:D
Authorized Official - Last Name:COWART
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:912-259-9633
Mailing Address - Street 1:911 MONARCH CIR
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-9197
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 HILL POND LN
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-0872
Practice Address - Country:US
Practice Address - Phone:912-259-9633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-26
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty