NPIMap

Organization Active NPI

Valdosta Medical Clinic

  • Multi-Specialty Clinic/Center
  • Valdosta, GA
National Provider Identifier
1538200035
Registry record updated Jan 29, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
Multi-Specialty Clinic/CenterTaxonomy code 261QM1300X
Legal business name
VALDOSTA MEDICAL CLINIC
Practice address
3207 Country Club Dr
Valdosta, GA 31605-1029
Phone
(229) 242-8480
Fax
(229) 241-0252
NPI assigned
Feb 9, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 29, 2015

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

Authorized official

Name
Robin Bush, MANAGER
Title
Manager
Phone
(229) 242-8480

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Multi-Specialty Clinic/Center 261QM1300X Primary

Addresses

Primary practice location

3207 Country Club Dr
Valdosta, GA 31605-1029

Mailing address

3207 Country Club Dr.
Valdosta, GA 31605
Phone (229) 242-8480

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20041222000501 GA Part B Supplier - Clinic/Group Practice 9234197286 Receives reassigned benefits from 16 practitioners
Practice locations: Valdosta, GA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
11D0265607SGMC Valdosta Medical Clinic3207 Country Club Drive, Valdosta, GA 31605Certificate of waiverFeb 14, 2028

National Provider Directory

National Provider Directory

Interoperability endpoints

  • Direct secure messaging: anthony.johnson@valdostamed.gadirect.net
  • Direct secure messaging: kg.kumar@valdostamed.gadirect.net
  • Direct secure messaging: landis.gordon@valdostamed.gadirect.net
  • Direct secure messaging: thomas.hobby@valdostamed.gadirect.net
  • Direct secure messaging: alyson.lerstang@valdostamed.gadirect.net

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 16

NPI Registry JSON

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

{
    "created_epoch": "1170979200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1422489600000",
    "number": "1538200035",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3207 COUNTRY CLUB DR.",
            "city": "VALDOSTA",
            "state": "GA",
            "postal_code": "31605",
            "telephone_number": "229-242-8480",
            "fax_number": "229-242-0070"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3207 COUNTRY CLUB DR",
            "city": "VALDOSTA",
            "state": "GA",
            "postal_code": "316051029",
            "telephone_number": "229-242-8480",
            "fax_number": "229-241-0252"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "VALDOSTA MEDICAL CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-02-09",
        "last_updated": "2015-01-29",
        "status": "A",
        "authorized_official_last_name": "BUSH",
        "authorized_official_first_name": "ROBIN",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "229-242-8480",
        "authorized_official_credential": "MANAGER"
    },
    "taxonomies": [
        {
            "code": "261QM1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Multi-Specialty",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Valdosta, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 29, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.