Provider Demographics
NPI:1700237633
Name:ELLIJAY URGENT CARE & FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:ELLIJAY URGENT CARE & FAMILY PRACTICE LLC
Other - Org Name:ELLIJAY URGENT CARE & FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLIJAY URGENT CARE
Authorized Official - Middle Name:FAMILY
Authorized Official - Last Name:PRACTICE.
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:706-635-5177
Mailing Address - Street 1:97 HEFNER ST STE 202
Mailing Address - Street 2:
Mailing Address - City:EAST ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-8268
Mailing Address - Country:US
Mailing Address - Phone:706-635-2273
Mailing Address - Fax:706-635-2274
Practice Address - Street 1:97 HEFNER ST STE 202
Practice Address - Street 2:
Practice Address - City:EAST ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-8268
Practice Address - Country:US
Practice Address - Phone:706-635-5177
Practice Address - Fax:706-635-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-22
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062579207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty