Provider Demographics
NPI:1568747103
Name:DOROTHY SALLIS-STEWART MD, PC
Entity Type:Organization
Organization Name:DOROTHY SALLIS-STEWART MD, PC
Other - Org Name:J. I. L. FAMILY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:SALLIS
Authorized Official - Last Name:STEWART
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-453-2606
Mailing Address - Street 1:325 N COBB ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-7640
Mailing Address - Country:US
Mailing Address - Phone:478-453-2606
Mailing Address - Fax:478-453-2655
Practice Address - Street 1:325 N COBB ST
Practice Address - Street 2:SUITE A
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-7640
Practice Address - Country:US
Practice Address - Phone:478-453-2606
Practice Address - Fax:478-453-2655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-14
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046565261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000810345BMedicaid