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NPI Code Detail

MEDICARE: NORTHLAKE MEDICAL CENTER, LLC

MEDICARE: NORTHLAKE MEDICAL CENTER, LLC
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
1273Y00000XRehabilitation Hospital Unit

General Provider Information

NPI Number : 1164476123
Entity Type Code : Organization
Provider Name (Legal Business Name) : NORTHLAKE MEDICAL CENTER, LLC
Provider Business Mailing Address
First Line : 1455 MONTREAL RD
Second Line :
City : TUCKER
State : GA
Zip : 30084-8100
Country : US
Telephone Number : 770-270-3000
Fax Number : 770-270-3199
Provider Business Practice Location Address
First Line : 1455 MONTREAL RD
Second Line :
City : TUCKER
State : GA
Zip : 30084-8100
Country : US
Telephone Number : 770-270-3000
Fax Number : 770-270-3199
Authorized Official
Title or Position : CFO
Name : MICHAEL GORDIAN
Credential :
Telephone Number : 770-270-3010
Provider Enumeration Date : 05/22/2006
Last Update Date : 08/22/2020

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