Provider Demographics
NPI:1831201383
Name:BRIDGEWATER FAMILY PRACTICE, PC
Entity type:Organization
Organization Name:BRIDGEWATER FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:MANNING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-922-3522
Mailing Address - Street 1:2215 EXCHANGE PL SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-6723
Mailing Address - Country:US
Mailing Address - Phone:770-922-3522
Mailing Address - Fax:770-922-3662
Practice Address - Street 1:2215 EXCHANGE PL SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-6723
Practice Address - Country:US
Practice Address - Phone:770-922-3522
Practice Address - Fax:770-922-3662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA7598486OtherAETNA GROUP NUMBER
GA11D0938549OtherCLIA
GA11D0938549OtherCLIA
GAGRP3362Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
GACJ2580Medicare ID - Type UnspecifiedRAILROAD MEDICARE