Provider Demographics
NPI:1689802597
Name:FAMILY PRACTICE HEALTHCARE CLINIC/ URGENT CARE
Entity Type:Organization
Organization Name:FAMILY PRACTICE HEALTHCARE CLINIC/ URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMUND
Authorized Official - Middle Name:MATT
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:229-868-2831
Mailing Address - Street 1:10 NORTH 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MCRAE
Mailing Address - State:GA
Mailing Address - Zip Code:31055-4941
Mailing Address - Country:US
Mailing Address - Phone:229-868-2831
Mailing Address - Fax:229-520-3068
Practice Address - Street 1:10 NORTH 3RD AVE
Practice Address - Street 2:
Practice Address - City:MCRAE
Practice Address - State:GA
Practice Address - Zip Code:31055-4941
Practice Address - Country:US
Practice Address - Phone:229-868-2831
Practice Address - Fax:229-520-3068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN115997261QP2300X, 261QU0200X
GA037111261QP2300X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000539283JMedicaid
GARN115997OtherLICENSE NUMBER
GA202G086558Medicare PIN