Provider Demographics
NPI:1659477404
Name:CORDELE FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:CORDELE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:229-273-0841
Mailing Address - Street 1:501 THIRD AVENUE EAST
Mailing Address - Street 2:
Mailing Address - City:CORDELE
Mailing Address - State:GA
Mailing Address - Zip Code:31015
Mailing Address - Country:US
Mailing Address - Phone:229-273-0841
Mailing Address - Fax:229-273-0758
Practice Address - Street 1:501 THIRD AVENUE EAST
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015
Practice Address - Country:US
Practice Address - Phone:229-273-0841
Practice Address - Fax:229-273-0841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA22921207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00265218AMedicaid
GA00265218AMedicaid