Provider Demographics
NPI:1639619737
Name:COLUMBUS FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:COLUMBUS FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:E
Authorized Official - Last Name:FUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-324-4177
Mailing Address - Street 1:2827 WARM SPRINGS RD
Mailing Address - Street 2:3B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-5246
Mailing Address - Country:US
Mailing Address - Phone:706-324-4177
Mailing Address - Fax:706-322-9637
Practice Address - Street 1:2827 WARM SPRINGS RD
Practice Address - Street 2:3B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-5246
Practice Address - Country:US
Practice Address - Phone:706-324-4177
Practice Address - Fax:706-322-9637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2018-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000330063CMedicaid