MEDICARE: LILBURN MEDICAL CENTER PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	15063657	GA

General Provider Information

NPI Number	:	1083165294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LILBURN MEDICAL CENTER PC

Provider Business Mailing Address
First Line	:	4705 LAWRENCEVILLE HWY NW
Second Line	:	SUITE B
City	:	LILBURN
State	:	GA
Zip	:	30047-3667
Country	:	US
Telephone Number	:	770-880-5788
Fax Number	:	404-481-2062

Provider Business Practice Location Address
First Line	:	4705 LAWRENCEVILLE HWY NW
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-3667
Country	:	US
Telephone Number	:	770-880-5788
Fax Number	:	404-481-2062

Authorized Official
Title or Position	:	OWENER
Name	:	MINSHENG WANG
Credential	:	MD
Telephone Number	:	770-880-5788

Provider Enumeration Date	:	10/23/2016
Last Update Date	:	03/30/2017

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