Provider Demographics
NPI:1962460659
Name:CARTERSVILLE FAMILY MEDICINE, INC.
Entity Type:Organization
Organization Name:CARTERSVILLE FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JO
Authorized Official - Middle Name:MYERS
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-375-9180
Mailing Address - Street 1:2294 CARTERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23027-9701
Mailing Address - Country:US
Mailing Address - Phone:804-375-9180
Mailing Address - Fax:804-375-9297
Practice Address - Street 1:2294 CARTERSVILLE RD
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23027-9701
Practice Address - Country:US
Practice Address - Phone:804-375-9180
Practice Address - Fax:804-375-9297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101222830207Q00000X
VA0024129303207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAS67154Medicare UPIN
VAF78629Medicare UPIN