Provider Demographics
NPI:1699226001
Name:MIDDLE GEORGIA PRIMARY CARE
Entity Type:Organization
Organization Name:MIDDLE GEORGIA PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:APPAVUCHETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUNDAPPAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:478-988-3060
Mailing Address - Street 1:2350 HOUSTON LAKE ROAD
Mailing Address - Street 2:APT 1602
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047
Mailing Address - Country:US
Mailing Address - Phone:478-955-3722
Mailing Address - Fax:
Practice Address - Street 1:1115 MORNINGSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069
Practice Address - Country:US
Practice Address - Phone:478-988-3060
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA215936363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty