Provider Demographics
NPI:1720393895
Name:PIONEER HEALTH SERVICES OF EARLY COUNTY, LLC
Entity Type:Organization
Organization Name:PIONEER HEALTH SERVICES OF EARLY COUNTY, LLC
Other - Org Name:PIONEER FAMILY MEDICAL OF EARLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-849-1682
Mailing Address - Street 1:11045 COLUMBIA ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-3447
Mailing Address - Country:US
Mailing Address - Phone:229-723-4313
Mailing Address - Fax:229-723-3734
Practice Address - Street 1:11045 COLUMBIA ST
Practice Address - Street 2:SUITE B
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-3447
Practice Address - Country:US
Practice Address - Phone:229-723-4313
Practice Address - Fax:229-723-3734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA118509Medicare PIN