Provider Demographics
NPI:1548559339
Name:FAIRMOUNT FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:FAIRMOUNT FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:706-337-1930
Mailing Address - Street 1:PO BOX 703
Mailing Address - Street 2:
Mailing Address - City:FAIRMOUNT
Mailing Address - State:GA
Mailing Address - Zip Code:30139-0703
Mailing Address - Country:US
Mailing Address - Phone:706-337-1930
Mailing Address - Fax:706-337-1910
Practice Address - Street 1:2712 HIGHWAY 411 SE
Practice Address - Street 2:
Practice Address - City:FAIRMOUNT
Practice Address - State:GA
Practice Address - Zip Code:30139-3219
Practice Address - Country:US
Practice Address - Phone:706-337-1930
Practice Address - Fax:706-337-1910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-01
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA32319207Q00000X
GARN107315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty