Provider Demographics
NPI:1689935306
Name:SOUTH GEORGIA PRIMARY CARE, INC.
Entity Type:Organization
Organization Name:SOUTH GEORGIA PRIMARY CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:912-632-8244
Mailing Address - Street 1:204 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:GA
Mailing Address - Zip Code:31510-2908
Mailing Address - Country:US
Mailing Address - Phone:912-632-8244
Mailing Address - Fax:912-632-8315
Practice Address - Street 1:204 E 15TH ST
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:GA
Practice Address - Zip Code:31510-2908
Practice Address - Country:US
Practice Address - Phone:912-632-8244
Practice Address - Fax:912-632-8315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-30
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty