Provider Demographics
NPI:1629400312
Name:SOUTHWEST GA PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:SOUTHWEST GA PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:P
Authorized Official - Last Name:HAMSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:229-410-9965
Mailing Address - Street 1:PO BOX 989
Mailing Address - Street 2:
Mailing Address - City:ELLAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31806-0989
Mailing Address - Country:US
Mailing Address - Phone:229-410-9965
Mailing Address - Fax:229-937-9007
Practice Address - Street 1:93 S BROAD ST
Practice Address - Street 2:
Practice Address - City:ELLAVILLE
Practice Address - State:GA
Practice Address - Zip Code:31806-0989
Practice Address - Country:US
Practice Address - Phone:229-410-9965
Practice Address - Fax:229-937-9007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA33367261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000506437GMedicaid
GA000506437GMedicaid