MEDICARE: STONE MOUNTAIN IMMEDIATE MEDICAL CARE, INC.

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	302R00000X	Health Maintenance Organization
2	302R00000X	Health Maintenance Organization	038143	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578569323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STONE MOUNTAIN IMMEDIATE MEDICAL CARE, INC.

Provider Business Mailing Address
First Line	:	833 N HAIRSTON RD
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-3423
Country	:	US
Telephone Number	:	770-879-5553
Fax Number	:	770-879-5592

Provider Business Practice Location Address
First Line	:	833 N HAIRSTON RD
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30083-3423
Country	:	US
Telephone Number	:	770-879-5553
Fax Number	:	770-879-5592

Authorized Official
Title or Position	:	CREDENTIALING MGR
Name	:	MS. DORIS LYNN DAVIS
Credential	:
Telephone Number	:	770-879-5553

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	11/20/2022

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