Provider Demographics
NPI:1912056474
Name:FAMILY PRACTITIONERS OF GLYNN, PC
Entity Type:Organization
Organization Name:FAMILY PRACTITIONERS OF GLYNN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:KOTZ
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-267-4900
Mailing Address - Street 1:390 EH CT
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-2198
Mailing Address - Country:US
Mailing Address - Phone:912-267-4900
Mailing Address - Fax:912-267-4960
Practice Address - Street 1:390 EH CT
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-2198
Practice Address - Country:US
Practice Address - Phone:912-267-4900
Practice Address - Fax:912-267-4960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046996207Q00000X
GA029657207Q00000X
GA052698207Q00000X
GA056735207Q00000X
GA051731207Q00000X
GA040739207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7489Medicare PIN