Provider Demographics
NPI:1710058953
Name:MCDONOUGH PRIMARY CARE INC
Entity Type:Organization
Organization Name:MCDONOUGH PRIMARY CARE INC
Other - Org Name:KEYS FERRY MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HARRELL
Authorized Official - Last Name:VAN LAAR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-914-0342
Mailing Address - Street 1:68 HAMPTON ST
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3150
Mailing Address - Country:US
Mailing Address - Phone:770-914-0342
Mailing Address - Fax:770-914-0493
Practice Address - Street 1:68 HAMPTON ST
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3150
Practice Address - Country:US
Practice Address - Phone:770-914-0342
Practice Address - Fax:770-914-0493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000458455EMedicaid
GA000458455EMedicaid