Provider Demographics
NPI:1780244301
Name:HEART OF GEORGIA PRIMARY CARE, LLC
Entity type:Organization
Organization Name:HEART OF GEORGIA PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:H
Authorized Official - Last Name:CRAVEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:478-374-5774
Mailing Address - Street 1:911 PLAZA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-6786
Mailing Address - Country:US
Mailing Address - Phone:478-374-5774
Mailing Address - Fax:912-374-9112
Practice Address - Street 1:911 PLAZA AVE STE C
Practice Address - Street 2:
Practice Address - City:EASTMAN
Practice Address - State:GA
Practice Address - Zip Code:31023-6786
Practice Address - Country:US
Practice Address - Phone:478-374-5774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-17
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA296546508FMedicaid
GACS2005900319OtherCARESOURCE PROVIDER NUMBER