Healthcare Provider Details

I. General information

NPI: 1033589171
Provider Name (Legal Business Name): SUBURBAN HOME VISITS MHT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2015
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 RIVEREDGE PKWY SUITE 104
ATLANTA GA
30328-4694
US

IV. Provider business mailing address

1575 HERITAGE DR SUITE 205
MCKINNEY TX
75069-3288
US

V. Phone/Fax

Practice location:
  • Phone: 469-307-5810
  • Fax: 877-489-3949
Mailing address:
  • Phone: 469-307-5810
  • Fax: 877-489-3949

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35763
License Number StateGA

VIII. Authorized Official

Name: DR. EMILY JORDAN
Title or Position: VP OF PAYOR OPPERATIONS
Credential: MD
Phone: 469-307-5810