MEDICARE: MID PROVIDER 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	363LG0600X	Gerontology Nurse Practitioner	RN133089	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DD4864	OTHER	GA	RAILROAD RETIERMENT

General Provider Information

NPI Number	:	1962621532
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID PROVIDER INC

Provider Business Mailing Address
First Line	:	1230 WORTHINGTON HILLS DR
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30076-1753
Country	:	US
Telephone Number	:	404-229-0274
Fax Number	:	770-518-4026

Provider Business Practice Location Address
First Line	:	1230 WORTHINGTON HILLS DR
Second Line	:
City	:	ROSWELL
State	:	GA
Zip	:	30076-1753
Country	:	US
Telephone Number	:	404-229-0274
Fax Number	:	770-518-4026

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MRS. PATRICIA J NORRIS
Credential	:	GNP
Telephone Number	:	404-229-0274

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	01/05/2010

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Directions to “MID PROVIDER INC ” Practice Location

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