Provider Demographics
NPI:1659592137
Name:SOUTH COLUMBUS FAMILY PRACTICE
Entity Type:Organization
Organization Name:SOUTH COLUMBUS FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:SHABBIR
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTIWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-685-2770
Mailing Address - Street 1:4000 SAINT MARYS RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-7626
Mailing Address - Country:US
Mailing Address - Phone:706-685-2770
Mailing Address - Fax:706-685-3299
Practice Address - Street 1:4000 SAINT MARYS RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-7626
Practice Address - Country:US
Practice Address - Phone:706-685-2770
Practice Address - Fax:706-685-3299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036581207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA303731Medicaid
GA08BBWSBMedicare ID - Type Unspecified
GAF52927Medicare UPIN