Healthcare Provider Details

I. General information

NPI: 1952599516
Provider Name (Legal Business Name): SOUTH FORSYTH FAMILY MEDICINE AND PEDIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 LOCKEWAY DR SUITE 404
ALPHARETTA GA
30004-5936
US

IV. Provider business mailing address

1845 LOCKEWAY DR SUITE 404
ALPHARETTA GA
30004-5936
US

V. Phone/Fax

Practice location:
  • Phone: 770-343-9112
  • Fax: 770-343-8911
Mailing address:
  • Phone: 770-343-9112
  • Fax: 770-343-8911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2401782
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2401782
License Number StateGA

VIII. Authorized Official

Name: MRS. DINA J GORE
Title or Position: MEDICAL BILLING & INSURANCE MANAGER
Credential:
Phone: 770-343-9112