Provider Demographics
NPI:1598981664
Name:FAMILY MEDICINE ASSOCIATES OF DALTON PC
Entity Type:Organization
Organization Name:FAMILY MEDICINE ASSOCIATES OF DALTON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TRIGGS
Authorized Official - Last Name:BOYETT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:706-529-1765
Mailing Address - Street 1:1243 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2800
Mailing Address - Country:US
Mailing Address - Phone:706-529-1765
Mailing Address - Fax:706-529-7438
Practice Address - Street 1:1243 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2800
Practice Address - Country:US
Practice Address - Phone:706-529-1765
Practice Address - Fax:706-529-7438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048758207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA257154400Medicaid
GAE3239ZMedicare ID - Type Unspecified
GAH05842Medicare UPIN