Provider Demographics
NPI:1982744082
Name:MOULTRIE INTERNAL MEDICINE ASSOCIATES PC
Entity Type:Organization
Organization Name:MOULTRIE INTERNAL MEDICINE ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAMON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:229-985-5200
Mailing Address - Street 1:320 SUNSET CIR
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31768-6924
Mailing Address - Country:US
Mailing Address - Phone:229-985-5200
Mailing Address - Fax:
Practice Address - Street 1:320 SUNSET CIR
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6924
Practice Address - Country:US
Practice Address - Phone:229-985-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21172207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00220349CMedicaid
GAD70522Medicare UPIN