Provider Demographics
NPI:1760598643
Name:CHATTAHOOCHEE VALLEY FAMILY
Entity Type:Organization
Organization Name:CHATTAHOOCHEE VALLEY FAMILY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-291-8322
Mailing Address - Street 1:1810 STADIUM DRIVE STE 240
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867
Mailing Address - Country:US
Mailing Address - Phone:334-291-8303
Mailing Address - Fax:334-291-8325
Practice Address - Street 1:1810 STADIUM DRIVE STE 240
Practice Address - Street 2:
Practice Address - City:PHENIX CITY
Practice Address - State:AL
Practice Address - Zip Code:36867
Practice Address - Country:US
Practice Address - Phone:334-291-8303
Practice Address - Fax:334-291-8325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52669717-001OtherBCBS GA
AL51512167OtherBCBS AL
AL009907915Medicaid
AL009907905Medicaid
GA52051956-003OtherBCBS GA
AL51512168OtherBCBS AL
GA080191085Medicare PIN
AL51512167OtherBCBS AL
GA52051956-003OtherBCBS GA
ALC72171Medicare UPIN
GAGRP4850Medicare PIN
GA080191086Medicare PIN