Provider Demographics
NPI:1720146301
Name:FAMILY PRACTICE OF CONYERS INC
Entity Type:Organization
Organization Name:FAMILY PRACTICE OF CONYERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-922-0076
Mailing Address - Street 1:1039 E FREEWAY DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5965
Mailing Address - Country:US
Mailing Address - Phone:770-922-0076
Mailing Address - Fax:770-922-0734
Practice Address - Street 1:1039 E FREEWAY DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5965
Practice Address - Country:US
Practice Address - Phone:770-922-0076
Practice Address - Fax:770-922-0734
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
GA032107173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00412849IMedicaid
GA00412849IMedicaid