MEDICARE: MODERN INTERNAL MEDICINE

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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1982095360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN INTERNAL MEDICINE

Provider Business Mailing Address
First Line	:	2457 MARTIN LUTHER KING JR DR SW
Second Line	:	SUITE A
City	:	ATLANTA
State	:	GA
Zip	:	30311-1712
Country	:	US
Telephone Number	:	404-368-8655
Fax Number	:

Provider Business Practice Location Address
First Line	:	2457 MARTIN LUTHER KING JR DR SW
Second Line	:	SUITE A
City	:	ATLANTA
State	:	GA
Zip	:	30311-1712
Country	:	US
Telephone Number	:	404-368-8655
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DEANDRE GREEN
Credential	:
Telephone Number	:	404-368-8655

Provider Enumeration Date	:	02/06/2015
Last Update Date	:	02/06/2015

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