Provider Demographics
NPI:1912957192
Name:GEORGIA PHYSICIANS GROUP, LLC
Entity Type:Organization
Organization Name:GEORGIA PHYSICIANS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-433-0635
Mailing Address - Street 1:2500 WEST BROAD STREET
Mailing Address - Street 2:SUITE 106
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606
Mailing Address - Country:US
Mailing Address - Phone:706-433-0635
Mailing Address - Fax:706-354-0529
Practice Address - Street 1:1063 BAXTER ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3773
Practice Address - Country:US
Practice Address - Phone:706-433-0635
Practice Address - Fax:706-354-0529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023937174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty