Provider Demographics
NPI:1710965900
Name:FORD CLINIC, INC
Entity Type:Organization
Organization Name:FORD CLINIC, INC
Other - Org Name:NORTHEAST GEORGIA MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:706-245-7380
Mailing Address - Street 1:24 HARTWELL ST
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-4213
Mailing Address - Country:US
Mailing Address - Phone:706-245-7380
Mailing Address - Fax:706-245-6726
Practice Address - Street 1:11973 AUGUSTA RD
Practice Address - Street 2:
Practice Address - City:LAVONIA
Practice Address - State:GA
Practice Address - Zip Code:30553-1283
Practice Address - Country:US
Practice Address - Phone:706-356-8181
Practice Address - Fax:706-356-8081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Not Answered261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC132982Medicaid
GA85001253GMedicaid
GA85001253GMedicaid