| Locust Grove Family Medicine | |
|
3778 Highway 42 Locust Grove GA 30248-3632 | |
| (678) 610-6649 | |
| (678) 610-6025 |
| Full Name | Locust Grove Family Medicine |
|---|---|
| Speciality | Non-Pharmacy Dispensing Site |
| Location | 3778 Highway 42, Locust Grove, Georgia |
| Authorized Official Name and Position | Nimisha J Trivedi (OWNER) |
| Authorized Official Contact | 6786106649 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Locust Grove Family Medicine 3778 Highway 42 Locust Grove GA 30248-3632 Ph: (678) 610-6649 | Locust Grove Family Medicine 3778 Highway 42 Locust Grove GA 30248-3632 Ph: (678) 610-6649 |
| NPI Number | 1629169164 |
|---|---|
| Provider Enumeration Date | 09/28/2006 |
| Last Update Date | 03/14/2016 |
| Medicare PECOS PAC ID | 1052306008 |
|---|---|
| Medicare Enrollment ID | O20040419000601 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629169164 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 053715 (Georgia) | Secondary |
| 332900000X | Non-pharmacy Dispensing Site | 053715 (Georgia) | Primary |
| Provider Name | Nimisha Trivedi |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1629074299 PECOS PAC ID: 2668467622 Enrollment ID: I20040420000918 |
| Provider Name | Chetan Sharma |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1871763011 PECOS PAC ID: 7113195082 Enrollment ID: I20110720000133 |
| Provider Name | Tina K Jordan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1255703088 PECOS PAC ID: 0840590014 Enrollment ID: I20151120000872 |
| Provider Name | Althea Dimaculangan |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1609255066 PECOS PAC ID: 0345525036 Enrollment ID: I20170320002236 |
| Provider Name | Remonne Joseph |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1801252176 PECOS PAC ID: 0941558563 Enrollment ID: I20180730002081 |
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