Provider Demographics
NPI:1669660783
Name:FAMILY CARE GROUP OF THOMSON, INC
Entity Type:Organization
Organization Name:FAMILY CARE GROUP OF THOMSON, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DARYL
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-595-1090
Mailing Address - Street 1:315 FLUKER ST
Mailing Address - Street 2:
Mailing Address - City:THOMSON
Mailing Address - State:GA
Mailing Address - Zip Code:30824-2108
Mailing Address - Country:US
Mailing Address - Phone:706-595-1090
Mailing Address - Fax:706-595-6010
Practice Address - Street 1:315 FLUKER ST
Practice Address - Street 2:
Practice Address - City:THOMSON
Practice Address - State:GA
Practice Address - Zip Code:30824-2108
Practice Address - Country:US
Practice Address - Phone:706-595-1090
Practice Address - Fax:706-595-6010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032327207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4411OtherMEDICARE GROUP NUMBER