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NPI Code Detail

MEDICARE: SOUTHSIDE MEDICAL CARE II LLC

MEDICARE: SOUTHSIDE MEDICAL CARE II 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
1207Q00000XFamily Medicine PhysicianGA

General Provider Information

NPI Number : 1972730562
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHSIDE MEDICAL CARE II LLC
Provider Business Mailing Address
First Line : 5909 PEACHTREE DUNWOODY RD NE
Second Line : SUITE 900
City : ATLANTA
State : GA
Zip : 30328-8102
Country : US
Telephone Number : 404-943-0205
Fax Number : 404-943-0209
Provider Business Practice Location Address
First Line : 6325 SHANNON PKWY
Second Line : SUITE D
City : UNION CITY
State : GA
Zip : 30291-1538
Country : US
Telephone Number : 404-943-0205
Fax Number : 404-943-0209
Authorized Official
Title or Position : BILLING MANAGER
Name : MS. ALICIA HOLDEN
Credential :
Telephone Number : 404-943-0205
Provider Enumeration Date : 06/22/2009
Last Update Date : 06/22/2009

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Directions to “SOUTHSIDE MEDICAL CARE II LLC ” Practice Location

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