Provider Demographics
NPI:1679221030
Name:ADVANCE CARE MEDICAL PCP GEORGIA, INC.
Entity Type:Organization
Organization Name:ADVANCE CARE MEDICAL PCP GEORGIA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-668-2188
Mailing Address - Street 1:3 SCHOOL ST STE 303
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-2548
Mailing Address - Country:US
Mailing Address - Phone:866-668-2188
Mailing Address - Fax:
Practice Address - Street 1:5749 WENDY BAGWELL PKWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2815
Practice Address - Country:US
Practice Address - Phone:866-668-2188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty