NPIMap

Organization Active NPI

Malozera Primary Care, LLC

  • Family Medicine Physician
  • Unadilla, GA
National Provider Identifier
1912544784
Registry record updated Nov 18, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
MALOZERA PRIMARY CARE, LLC
Practice address
2809 Pine St
Unadilla, GA 31091-7701
Phone
(478) 355-3000
Fax
(478) 355-3001
NPI assigned
Nov 29, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 18, 2023

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

Authorized official

Name
Dr. Alexander C Ibezi-Enendu, DONPI 1154615979
Title
Owner
Phone
(404) 702-9466

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

2809 Pine St
Unadilla, GA 31091-7701

Mailing address

P O Box 8203
Warner Robins, GA 31095-8203
Phone (478) 783-3610

Other practice location 1

604 Bluebird Blvd
Fort Valley, GA 31030-5081
Phone (478) 352-2031

Other practice location 2

292 Industrial Blvd Ste 300
Hawkinsville, GA 31036-8034
Phone (478) 783-3610

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200129000718 GA Part B Supplier - Clinic/Group Practice 4789010430 Receives reassigned benefits from 2 practitioners
Practice locations: Fort Valley, GA; Unadilla, GA; Warner Robins, 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
11D2285307Malozera Primary Care,LLC2809 Pine Street, Unadilla, GA 31091Certificate of waiverJul 10, 2027

National Provider Directory

National Provider Directory

Locations

292 Industrial Blvd
Ste 300
Hawkinsville, GA 31036
Phone (478) 783-3610

Practitioners & affiliated clinicians

Practitioners 2

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

NPI Registry JSON

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

{
    "created_epoch": "1574985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1700265600000",
    "number": "1912544784",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "P O BOX 8203",
            "city": "WARNER ROBINS",
            "state": "GA",
            "postal_code": "310958203",
            "telephone_number": "478-783-3610",
            "fax_number": "478-783-3611"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2809 PINE ST",
            "city": "UNADILLA",
            "state": "GA",
            "postal_code": "310917701",
            "telephone_number": "478-355-3000",
            "fax_number": "478-355-3001"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "604 Bluebird Blvd",
            "address_purpose": "LOCATION",
            "city": "Fort Valley",
            "state": "GA",
            "postal_code": "310305081",
            "country_code": "US",
            "telephone_number": "478-352-2031",
            "fax_number": "478-825-2041",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "292 Industrial Blvd Ste 300",
            "address_purpose": "LOCATION",
            "city": "Hawkinsville",
            "state": "GA",
            "postal_code": "310368034",
            "country_code": "US",
            "telephone_number": "478-783-3610",
            "fax_number": "478-783-3611",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MALOZERA PRIMARY CARE, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-11-29",
        "last_updated": "2023-11-18",
        "certification_date": "2023-11-18",
        "status": "A",
        "authorized_official_last_name": "IBEZI-ENENDU",
        "authorized_official_first_name": "ALEXANDER",
        "authorized_official_middle_name": "C",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "404-702-9466",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Unadilla, GA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 18, 2023; 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.