Provider Demographics
NPI:1134334832
Name:POWDER SPRINGS MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:POWDER SPRINGS MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-943-1636
Mailing Address - Street 1:4045B LINDLEY CIR
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-2711
Mailing Address - Country:US
Mailing Address - Phone:770-943-1636
Mailing Address - Fax:770-943-7941
Practice Address - Street 1:4045-B LINDLEY CIR
Practice Address - Street 2:
Practice Address - City:POWDER SOPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127
Practice Address - Country:US
Practice Address - Phone:770-943-1636
Practice Address - Fax:770-943-7941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2008-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA019698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0100673OtherUNITED HEALTHCARE
GA10041190OtherAMERIGROUP
GA4569669OtherAETNA
GAP00256198OtherRAILROAD MEDICARE
GA3661647OtherCIGNA
GA52143080OtherBCBS
GA314139OtherWELLCARE
GAGRP3770OtherMEDICARE GROUP
GA10041190OtherAMERIGROUP