Provider Demographics
NPI:1689765083
Name:NORTHWEST GEORGIA FAMILY PRACTICE CENTER, PC
Entity Type:Organization
Organization Name:NORTHWEST GEORGIA FAMILY PRACTICE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SPIVEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:706-857-5402
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30747-0409
Mailing Address - Country:US
Mailing Address - Phone:706-857-5402
Mailing Address - Fax:706-857-1800
Practice Address - Street 1:68 STOCKADE RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:GA
Practice Address - Zip Code:30747-1900
Practice Address - Country:US
Practice Address - Phone:706-857-5402
Practice Address - Fax:706-857-1800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty