Healthcare Provider Details

I. General information

NPI: 1437576659
Provider Name (Legal Business Name): SPECTRUM INTERNAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2014
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 S MAIN ST SUITE B3
ALPHARETTA GA
30009-1974
US

IV. Provider business mailing address

401 S MAIN ST SUITE B3
ALPHARETTA GA
30009-1974
US

V. Phone/Fax

Practice location:
  • Phone: 678-319-9901
  • Fax: 678-319-9902
Mailing address:
  • Phone: 678-319-9901
  • Fax: 678-319-9902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number58939
License Number StateGA

VIII. Authorized Official

Name: DR. JULIUS KOLAWOLE ADEBISI
Title or Position: MEDICAL DIRECTOR
Credential: M.D
Phone: 678-319-9901