Provider Demographics
NPI:1619118015
Name:GEORGIA MEDPORT LLC
Entity Type:Organization
Organization Name:GEORGIA MEDPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:WILLIAMS
Authorized Official - Last Name:NIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-535-2601
Mailing Address - Street 1:PO BOX 2306
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-2306
Mailing Address - Country:US
Mailing Address - Phone:770-535-2601
Mailing Address - Fax:770-535-2602
Practice Address - Street 1:1002 CHESTNUT ST SE
Practice Address - Street 2:SUITE A
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-6909
Practice Address - Country:US
Practice Address - Phone:770-535-2601
Practice Address - Fax:770-535-2602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-13
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA069-193416L0300X
343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003108574AMedicaid
GA202G593924OtherMEDICARE