Provider Demographics
NPI:1518398049
Name:NORMAN PARK FAMILY MEDICINE CLINIC
Entity Type:Organization
Organization Name:NORMAN PARK FAMILY MEDICINE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:
Authorized Official - Last Name:MERDIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-890-3531
Mailing Address - Street 1:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:NORMAN PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31771-0110
Mailing Address - Country:US
Mailing Address - Phone:229-769-3500
Mailing Address - Fax:229-769-3501
Practice Address - Street 1:139 EAST BROAD STREET
Practice Address - Street 2:
Practice Address - City:NORMAN PARK
Practice Address - State:GA
Practice Address - Zip Code:31771
Practice Address - Country:US
Practice Address - Phone:229-769-3500
Practice Address - Fax:229-769-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-10
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11-8912OtherMEDICARE PART A
GA003155331AMedicaid