Provider Demographics
NPI:1649449323
Name:DR RAYMOND J OTIS SR PC
Entity type:Organization
Organization Name:DR RAYMOND J OTIS SR PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:J
Authorized Official - Last Name:OTIS
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:229-336-7343
Mailing Address - Street 1:PO BOX 348
Mailing Address - Street 2:
Mailing Address - City:CAMILLA
Mailing Address - State:GA
Mailing Address - Zip Code:31730-0348
Mailing Address - Country:US
Mailing Address - Phone:229-336-7343
Mailing Address - Fax:229-336-7400
Practice Address - Street 1:24 N ELLIS ST
Practice Address - Street 2:
Practice Address - City:CAMILLA
Practice Address - State:GA
Practice Address - Zip Code:31730-1502
Practice Address - Country:US
Practice Address - Phone:229-336-7343
Practice Address - Fax:229-336-7400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
GA42685261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0720266DMedicaid
GA08BBQMNMedicare PIN
GAG34201Medicare UPIN