MEDICARE: PACIFIC MEDICAL 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
1	261QE0002X	Emergency Care Clinic/Center	050724	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	GRP7518	OTHER	GA	GRP#

General Provider Information

NPI Number	:	1417011099
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFIC MEDICAL LLC

Provider Business Mailing Address
First Line	:	1730 MOUNT VERNON RD
Second Line	:	SUITE B
City	:	DUNWOODY
State	:	GA
Zip	:	30338-4245
Country	:	US
Telephone Number	:	770-353-2001
Fax Number	:	770-353-2010

Provider Business Practice Location Address
First Line	:	1730 MOUNT VERNON RD
Second Line	:	SUITE B
City	:	DUNWOODY
State	:	GA
Zip	:	30338-4245
Country	:	US
Telephone Number	:	770-353-2001
Fax Number	:	770-353-2010

Authorized Official
Title or Position	:	OWNER,PHYSICIAN
Name	:	DR. CASEY N LOCARNINI
Credential	:	M.D.
Telephone Number	:	770-353-2001

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	02/11/2009

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