Provider Demographics
NPI:1942312319
Name:COLONY MEDICAL ASSOCIATES PC
Entity type:Organization
Organization Name:COLONY MEDICAL ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-423-2058
Mailing Address - Street 1:PO BOX 929
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-0929
Mailing Address - Country:US
Mailing Address - Phone:229-423-2058
Mailing Address - Fax:229-423-0197
Practice Address - Street 1:110 NORMAN DORMINY DR
Practice Address - Street 2:SUITE B
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8858
Practice Address - Country:US
Practice Address - Phone:229-423-2058
Practice Address - Fax:229-423-0197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056020174400000X
GA053043174400000X
GARN101986363LF0000X
GA33123174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBKJPOtherMEDICARE
GAP00232517OtherRAILROAD MEDICARE
GA00427798AMedicaid
GA500002323OtherRAILROAD MEDICARE
GACB5821OtherRAILROAD MEDICARE GROUP
GA08BDBZBMedicare ID - Type Unspecified
GACB5821OtherRAILROAD MEDICARE GROUP
GAC72449Medicare UPIN
GACB5821OtherRAILROAD MEDICARE GROUP
GAI32726Medicare UPIN
GA08BDBZBMedicare ID - Type Unspecified
GA500002323OtherRAILROAD MEDICARE
GAI03788Medicare UPIN
GAS27607Medicare UPIN
GA11SCFDCMedicare ID - Type Unspecified