Provider Demographics
NPI:1659571818
Name:ELIZABETH FAMILY PRACTICE CENTER
Entity Type:Organization
Organization Name:ELIZABETH FAMILY PRACTICE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OBAYODE
Authorized Official - Middle Name:
Authorized Official - Last Name:AYEWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:912-352-9001
Mailing Address - Street 1:15 MEDICAL ARTS CTR
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-4414
Mailing Address - Country:US
Mailing Address - Phone:912-352-9001
Mailing Address - Fax:912-629-0468
Practice Address - Street 1:15 MEDICAL ARTS CTR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4414
Practice Address - Country:US
Practice Address - Phone:912-352-9001
Practice Address - Fax:912-629-0468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI25308Medicare UPIN
GAGRP7289Medicare PIN