Provider Demographics
NPI:1750329249
Name:WEST GEORGIA FAMILY MEDICINE ASSOCIATES, PA
Entity Type:Organization
Organization Name:WEST GEORGIA FAMILY MEDICINE ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DEBBI
Authorized Official - Middle Name:
Authorized Official - Last Name:MACALUSO-PEARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-838-8554
Mailing Address - Street 1:119 AMBULANCE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3857
Mailing Address - Country:US
Mailing Address - Phone:770-459-4411
Mailing Address - Fax:770-459-1898
Practice Address - Street 1:705 DALLAS HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1247
Practice Address - Country:US
Practice Address - Phone:770-459-4411
Practice Address - Fax:770-459-1898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000207567AMedicaid
GAGRP1067Medicare ID - Type Unspecified