Provider Demographics
NPI:1043381361
Name:ANGLYN FAMILY MEDICAL CENTER, LLC
Entity type:Organization
Organization Name:ANGLYN FAMILY MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:R
Authorized Official - Last Name:ANGLYN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-957-3922
Mailing Address - Street 1:55 SIMS ST
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-2320
Mailing Address - Country:US
Mailing Address - Phone:770-957-3922
Mailing Address - Fax:770-957-5477
Practice Address - Street 1:55 SIMS ST
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-2320
Practice Address - Country:US
Practice Address - Phone:770-957-3922
Practice Address - Fax:770-957-5477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP 3309Medicare PIN