Provider Demographics
NPI:1932877610
Name:PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Entity Type:Organization
Organization Name:PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-723-2660
Mailing Address - Street 1:338 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-2554
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:283 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:BLAKELY
Practice Address - State:GA
Practice Address - Zip Code:39823-3455
Practice Address - Country:US
Practice Address - Phone:229-723-4101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMARY CARE OF SOUTHWEST GEORGIA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)