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Organization
FANNIN PHYSICIAN SERVICES LLC
Active
Organization
FANNIN PHYSICIAN SERVICES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LISHA C FALK (VP OF CONTRACTING)
(800) 893-9698
Entity
Organization
Contact information
Practice address
2855 OLD HIGHWAY 5, BLUE RIDGE, GA 30513-6248
(800) 893-9698
Mailing address
200 CORPORATE BLVD, LAFAYETTE, LA 70508-3870
(800) 893-9698
Taxonomy
Speciality
Code
Description
License number
State
208M00000X
Hospitalist Physician
Primary
—
GA
363A00000X
Physician Assistant
—
GA
363L00000X
Nurse Practitioner
—
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003162205A
—
GA
Enumeration date
02/06/2015
Last updated
07/11/2017
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