Provider Demographics
NPI:1902009194
Name:SOUTHERN FAMILY HEALTHCARE OF EASTMAN INC
Entity Type:Organization
Organization Name:SOUTHERN FAMILY HEALTHCARE OF EASTMAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:478-374-1308
Mailing Address - Street 1:1112 PLAZA AVE STE C
Mailing Address - Street 2:PO BOX 789
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-9012
Mailing Address - Country:US
Mailing Address - Phone:478-374-1308
Mailing Address - Fax:478-374-0302
Practice Address - Street 1:1112 PLAZA AVE
Practice Address - Street 2:SUITE C
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-9009
Practice Address - Country:US
Practice Address - Phone:478-374-1308
Practice Address - Fax:478-374-0302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038495207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID #