NPIMap

Organization Active NPI

DMC Physician Group LLC

  • Multi-Specialty Clinic/Center
  • Fitzgerald, GA
National Provider Identifier
1124430020
Registry record updated May 19, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
DMC PHYSICIAN GROUP LLC
Practice address
200 Perry House Rd
Fitzgerald, GA 31750-8857
Phone
(229) 424-7260
NPI assigned
May 27, 2014
Last updated
May 19, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 19, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Paige Wynn
Title
Interim Ceo
Phone
(478) 289-1376

Specialties & licenses 9

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X NU Primary
Rural Health Clinic/Center 261QR1300X NU
Psychiatric Hospital Unit 273R00000X NU
Rural Acute Care Hospital 282NR1301X NU
Certified Registered Nurse Anesthetist 367500000X NU
Family Medicine Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU
Surgery Physician 208600000X NU
Hospitalist Physician 208M00000X NU

Addresses

Primary practice location

200 Perry House Rd
Fitzgerald, GA 31750-8857

Mailing address

200 Perry House Rd
Fitzgerald, GA 31750-8857
Phone (229) 424-7260

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA3 enrollments

Enrollment records 3

Enrollment IDStateProvider typePAC IDDetails
O20140902000773 GA Part B Supplier - Clinic/Group Practice 8628296845 Receives reassigned benefits from 20 practitioners
Practice locations: Fitzgerald, GA
O20150209002132 GA Part A Provider - Rural Health Clinic 8628296845 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Fitzgerald, GA
O20180105000506 GA Part A Provider - Rural Health Clinic 8628296845 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Fitzgerald, GA

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1124430020. Details of each certification follow.

Rural health clinic certification: CCN 113466

Legal name
DMC PHYSICIAN GROUP LLC
Doing business as
DMC INTERNAL MEDICINE AND FAMILY HEALTH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Apr 16, 1997
Last certification
Feb 16, 2022
Ownership / control type
2B
Organization structure
LLCNon-profit
Incorporated
May 9, 2014 in GA
Enrollment address
118 Norman Dorminy Dr
Fitzgerald, GA 31750-8858
Related CCNs
110073

Rural health clinic certification: CCN 118572

Legal name
DMC PHYSICIAN GROUP LLC
Doing business as
DMC PRIMARY CARE
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Mar 25, 2020
Last certification
Apr 1, 2026
Ownership / control type
Non-profit – church related
Organization structure
LLCProprietary
Incorporated
May 9, 2014 in GA
Enrollment address
246 Benjamin H Hill Dr SW
Fitzgerald, GA 31750-8695
Related CCNs
111339

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 3

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Hospital Authority of Ben Hill Organization, Fitzgerald, GA 5% Or Greater Direct Ownership Interest Nov 1, 2014 100%
Paige P Wynn Individual W-2 Managing EmployeeChief Executive Officer Sep 3, 2021
Corporate OfficerChief Financial Officer Apr 21, 2021 100%
W-2 Managing EmployeeChief Financial Officer Apr 21, 2021 100%
Operational/Managerial ControlChief Financial Officer Apr 21, 2021 100%
Katherine Porter Individual Corporate DirectorDirector of Physician Office Operat Jan 1, 2023 100%
W-2 Managing EmployeeDirector of Physician Office Operat Jan 1, 2023 100%
Operational/Managerial ControlDirector of Physician Office Operat Jan 1, 2023 100%

Owners & managing parties with NPI records 4

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 21

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 21

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1401148800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1747612800000",
    "number": "1124430020",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "200 PERRY HOUSE RD",
            "city": "FITZGERALD",
            "state": "GA",
            "postal_code": "317508857",
            "telephone_number": "229-424-7260"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "200 PERRY HOUSE RD",
            "city": "FITZGERALD",
            "state": "GA",
            "postal_code": "317508857",
            "telephone_number": "229-424-7260"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DMC PHYSICIAN GROUP LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-05-27",
        "last_updated": "2025-05-19",
        "certification_date": "2025-05-19",
        "status": "A",
        "authorized_official_last_name": "WYNN",
        "authorized_official_first_name": "PAIGE",
        "authorized_official_title_or_position": "INTERIM CEO",
        "authorized_official_telephone_number": "478-289-1376",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "273R00000X",
            "taxonomy_group": "",
            "desc": "Psychiatric Unit",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "282NR1301X",
            "taxonomy_group": "",
            "desc": "General Acute Care Hospital, Rural",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "367500000X",
            "taxonomy_group": "",
            "desc": "Nurse Anesthetist, Certified Registered",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "208M00000X",
            "taxonomy_group": "",
            "desc": "Hospitalist",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fitzgerald, GA

Sources for this page

Verify at the official NPI Registry.