Healthcare Provider Details

I. General information

NPI: 1104100395
Provider Name (Legal Business Name): NOUVEAU MEDIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2011
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PHIPPS BLVD NE APT 1304
ATLANTA GA
30326-3342
US

IV. Provider business mailing address

600 PHIPPS BLVD NE APT 1304
ATLANTA GA
30326-3342
US

V. Phone/Fax

Practice location:
  • Phone: 678-653-0045
  • Fax: 404-393-3640
Mailing address:
  • Phone: 678-653-0045
  • Fax: 404-393-3640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number051126
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number051126
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207RI0001X
TaxonomyClinical & Laboratory Immunology (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JOY S EDWARDS
Title or Position: CLINICAL MANAGER
Credential: NMD, APRN,MPH
Phone: 678-653-0045