Provider Demographics
NPI:1700918919
Name:BARNESVILLE FAMILY MEDICINE, INC
Entity Type:Organization
Organization Name:BARNESVILLE FAMILY MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BERT
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-358-3284
Mailing Address - Street 1:PO BOX 4867
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31208-4867
Mailing Address - Country:US
Mailing Address - Phone:770-358-3284
Mailing Address - Fax:
Practice Address - Street 1:526 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:BARNESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30204-1713
Practice Address - Country:US
Practice Address - Phone:770-358-3284
Practice Address - Fax:770-358-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6466Medicare ID - Type UnspecifiedMEDICARE GROUP #