Healthcare Provider Details

I. General information

NPI: 1154859817
Provider Name (Legal Business Name): MDVIP MEDICAL GROUP GA-ATL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2017
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 HOWELL MILL RD NW STE 525
ATLANTA GA
30318-2538
US

IV. Provider business mailing address

1800 HOWELL MILL RD NW STE 525
ATLANTA GA
30318-3188
US

V. Phone/Fax

Practice location:
  • Phone: 404-537-8081
  • Fax: 404-367-3085
Mailing address:
  • Phone: 404-537-8081
  • Fax: 404-367-3085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREA KLEMES
Title or Position: CHIEF MEDICAL OFFICER
Credential: DO
Phone: 561-982-4300