Provider Demographics
NPI:1689667545
Name:S R ADCOCK MD PC
Entity Type:Organization
Organization Name:S R ADCOCK MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:F
Authorized Official - Last Name:DUKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-985-8713
Mailing Address - Street 1:1414 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-5812
Mailing Address - Country:US
Mailing Address - Phone:229-985-8713
Mailing Address - Fax:229-985-5013
Practice Address - Street 1:1414 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-5812
Practice Address - Country:US
Practice Address - Phone:229-985-8713
Practice Address - Fax:229-985-5013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21934207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00264063BMedicaid
GA00264063BMedicaid
D28751Medicare UPIN