Provider Demographics
NPI:1891752473
Name:WAYCROSS FAMILY PRACTICE
Entity Type:Organization
Organization Name:WAYCROSS FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-283-7220
Mailing Address - Street 1:1507 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-4530
Mailing Address - Country:US
Mailing Address - Phone:912-283-7220
Mailing Address - Fax:912-283-7026
Practice Address - Street 1:1507 ALICE ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-4530
Practice Address - Country:US
Practice Address - Phone:912-283-7220
Practice Address - Fax:912-283-7026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACB0726OtherRAILROAD MEDICARE
GAGRP926Medicare PIN