Healthcare Provider Details

I. General information

NPI: 1366583577
Provider Name (Legal Business Name): POLARIS MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 04/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1136 CLEVELAND AVE
ATLANTA GA
30344
US

IV. Provider business mailing address

1136 CLEVELAND AVE
ATLANTA GA
30344
US

V. Phone/Fax

Practice location:
  • Phone: 404-766-8110
  • Fax: 404-766-8106
Mailing address:
  • Phone: 404-766-8110
  • Fax: 404-766-8106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number052218
License Number StateGA

VIII. Authorized Official

Name: DR. LISA C PERRY-GILKES
Title or Position: CFO
Credential: M.D.
Phone: 404-766-8110