Provider Demographics
NPI:1689858805
Name:IMMEDIATE CARE CENTERS OF GEORGIA, LLC
Entity Type:Organization
Organization Name:IMMEDIATE CARE CENTERS OF GEORGIA, LLC
Other - Org Name:IMMEDIATE CARE CENTERS, TYRONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:B
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-895-0216
Mailing Address - Street 1:190 GREENCASTLE RD.
Mailing Address - Street 2:
Mailing Address - City:TRYONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290
Mailing Address - Country:US
Mailing Address - Phone:678-895-0216
Mailing Address - Fax:
Practice Address - Street 1:190 GREENCASTLE RD.
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290
Practice Address - Country:US
Practice Address - Phone:678-895-0216
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056526261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA152797525AMedicaid
GA123134Medicare UPIN
511I080113Medicare UPIN