Provider Demographics
NPI:1447438676
Name:TMC WEST GEORGIA FAMILY MEDICINE INC
Entity type:Organization
Organization Name:TMC WEST GEORGIA FAMILY MEDICINE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VP
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:DREILING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-838-8038
Mailing Address - Street 1:705 DALLAS HWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1247
Mailing Address - Country:US
Mailing Address - Phone:770-459-4411
Mailing Address - Fax:770-459-2424
Practice Address - Street 1:705 DALLAS HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1247
Practice Address - Country:US
Practice Address - Phone:770-459-4411
Practice Address - Fax:770-459-2424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700451Medicare Oscar/Certification