NPIMap

Organization Active NPI

DMC Physician Group LLC

Doing business as DMC Internal and Family Medicine Clinic

  • Rural Health Clinic/Center
  • Fitzgerald, GA
National Provider Identifier
1821662008
Registry record updated May 13, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
DMC PHYSICIAN GROUP LLC
Doing business as
DMC Internal and Family Medicine Clinic
DMC Internal Medicine and Family Health
Practice address
118 Norman Dorminy Dr
Fitzgerald, GA 31750-8858
Phone
(229) 423-9561
NPI assigned
May 13, 2021
Last updated
May 13, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 13, 2021

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

Authorized official

Name
Paige Wynn
Title
Ceo
Phone
(229) 424-7100

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X NU Primary
Family Medicine Physician 207Q00000X NU
Internal Medicine Physician 207R00000X NU

Addresses

Primary practice location

118 Norman Dorminy Dr
Fitzgerald, GA 31750-8858

Mailing address

PO Box 1447
Fitzgerald, GA 31750-1447
Phone (229) 424-7100

Other names 2

  • DMC INTERNAL AND FAMILY MEDICINE CLINIC Doing business as
  • DMC INTERNAL MEDICINE AND FAMILY HEALTH Doing business as

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20150209002132 GA Part A Provider - Rural Health Clinic 8628296845 1 other NPI on this enrollment
Practice locations: Fitzgerald, GA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1821662008. 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

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 1

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

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
11D2012744DMC Internal Medicine118 Norman Dorminy Drive, Fitzgerald, GA 31750Certificate of waiverSep 8, 2026

National Provider Directory

National Provider Directory
Tax ID family
DMC Physician Group LLC9 organizations share this tax ID, including this one

Other organizations with this tax ID 8

Organizations that report the same tax identification number in the National Provider Directory.

Locations

118 Norman Dorminy Dr
Fitzgerald, GA 31750
Phone (229) 423-9561

Ownership & related parties

All disclosed owners & managing parties 2

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

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 12

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.

NPI Registry JSON

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

{
    "created_epoch": "1620864000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1620864000000",
    "number": "1821662008",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1447",
            "city": "FITZGERALD",
            "state": "GA",
            "postal_code": "317501447",
            "telephone_number": "229-424-7100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "118 NORMAN DORMINY DR",
            "city": "FITZGERALD",
            "state": "GA",
            "postal_code": "317508858",
            "telephone_number": "229-423-9561"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DMC PHYSICIAN GROUP LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-05-13",
        "last_updated": "2021-05-13",
        "certification_date": "2021-04-21",
        "status": "A",
        "authorized_official_last_name": "WYNN",
        "authorized_official_first_name": "PAIGE",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "229-424-7100"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        },
        {
            "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
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "DMC INTERNAL AND FAMILY MEDICINE CLINIC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "DMC INTERNAL MEDICINE AND FAMILY HEALTH",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fitzgerald, GA

Sources for this page

Verify at the official NPI Registry.