Healthcare Provider Details

I. General information

NPI: 1457521940
Provider Name (Legal Business Name): STANFORD MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 06/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 MITCHELL ST SW SUITE 200
ATLANTA GA
30303-3439
US

IV. Provider business mailing address

142 MITCHELL ST SW SUITE 200
ATLANTA GA
30303-3439
US

V. Phone/Fax

Practice location:
  • Phone: 404-584-2105
  • Fax: 404-584-2106
Mailing address:
  • Phone: 404-584-2105
  • Fax: 404-584-2106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JEANETTE JUNCO PATINO
Title or Position: OWNER
Credential:
Phone: 786-837-1175