NPIMap

Organization Active NPI

Community Primary Care of Georgia LLC

  • Geriatric Medicine (Family Medicine) Physician
  • Gray, GA
National Provider Identifier
1336492511
Registry record updated Jun 28, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Geriatric Medicine (Family Medicine) PhysicianTaxonomy code 207QG0300X
Legal business name
COMMUNITY PRIMARY CARE OF GEORGIA LLC
Practice address
1005 Boulder Dr
Gray, GA 31032-6141
Phone
(478) 621-2100
Fax
(478) 744-0481
NPI assigned
Oct 25, 2012
Last updated
Jun 28, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 28, 2019

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

Authorized official

Name
Elize Joseph
Title
Director of Practice Management
Phone
(478) 621-2100

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Geriatric Medicine (Family Medicine) Physician 207QG0300X Primary

Addresses

Primary practice location

1005 Boulder Dr
Gray, GA 31032-6141

Mailing address

1005 Boulder Dr
Gray, GA 31032-6141
Phone (478) 621-2100

Other practice location 1

4421 Carnes St
Acworth, GA 30101-5305
Phone (478) 621-2072

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in GA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20121113000274 GA Part B Supplier - Clinic/Group Practice 0648421065 Receives reassigned benefits from 69 practitioners
Practice locations: Gray, GA

National Provider Directory

National Provider Directory

Locations

4421 Carnes St
Acworth, GA 30101
Phone (478) 621-2072

165 S Broad St
Butler, GA 31006
Phone (478) 862-2220

120 Spring St
Newnan, GA 30263
Phone (770) 253-1475

Ownership & related parties

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Heritage OaksSaint Simons Island, GA, CCN 115582 Skilled nursing facility Adp of the SNF Mar 1, 2025

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 71

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 71

NPI Registry JSON

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

{
    "created_epoch": "1351123200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1561680000000",
    "number": "1336492511",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1005 BOULDER DR",
            "city": "GRAY",
            "state": "GA",
            "postal_code": "310326141",
            "telephone_number": "478-621-2100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1005 BOULDER DR",
            "city": "GRAY",
            "state": "GA",
            "postal_code": "310326141",
            "telephone_number": "478-621-2100",
            "fax_number": "478-744-0481"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4421 Carnes St",
            "address_purpose": "LOCATION",
            "city": "Acworth",
            "state": "GA",
            "postal_code": "301015305",
            "country_code": "US",
            "telephone_number": "478-621-2072",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "COMMUNITY PRIMARY CARE OF GEORGIA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-10-25",
        "last_updated": "2019-06-28",
        "status": "A",
        "authorized_official_last_name": "JOSEPH",
        "authorized_official_first_name": "ELIZE",
        "authorized_official_title_or_position": "DIRECTOR OF PRACTICE MANAGEMENT",
        "authorized_official_telephone_number": "478-621-2100"
    },
    "taxonomies": [
        {
            "code": "207QG0300X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Geriatric Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Gray, GA

Sources for this page

Verify at the official NPI Registry.