MEDICARE: FAMILY MEDICAL CENTER P.C.

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	207QA0505X	Adult Medicine Physician	058527	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	058527	OTHER	GA	LICENSE NUMBER

General Provider Information

NPI Number	:	1184703779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY MEDICAL CENTER P.C.

Provider Business Mailing Address
First Line	:	5615 OLD NATIONAL HWY STE D
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-3817
Country	:	US
Telephone Number	:	770-997-2900
Fax Number	:	404-767-7053

Provider Business Practice Location Address
First Line	:	5615 OLD NATIONAL HWY STE D
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-3817
Country	:	US
Telephone Number	:	770-997-2900
Fax Number	:	404-767-7053

Authorized Official
Title or Position	:	CEO
Name	:	DR. SALLU MOHAMED JABATI
Credential	:	MD
Telephone Number	:	770-997-2900

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	07/16/2015

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