Provider Demographics
NPI:1043440530
Name:FAMILY MEDICAL AND URGENT CARE CLINIC OF MCDONOUGH, LLC
Entity type:Organization
Organization Name:FAMILY MEDICAL AND URGENT CARE CLINIC OF MCDONOUGH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:O
Authorized Official - Last Name:EIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-288-2822
Mailing Address - Street 1:1631 HWY 20 W
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7311
Mailing Address - Country:US
Mailing Address - Phone:770-288-2822
Mailing Address - Fax:770-288-2820
Practice Address - Street 1:1631 HWY 20 W
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-7311
Practice Address - Country:US
Practice Address - Phone:770-288-2822
Practice Address - Fax:770-288-2820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-20
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056874207Q00000X
GA004088363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty