Healthcare Provider Details

I. General information

NPI: 1972929685
Provider Name (Legal Business Name): WITHINME MD, ATLANTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2014
Last Update Date: 03/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 GLEN IRIS DR NE
ATLANTA GA
30308-2717
US

IV. Provider business mailing address

604 GLEN IRIS DR NE 5275 LEE HIGHWAY #201, ARLINGTON, VIRGINIA 22207
ATLANTA GA
30308-2717
US

V. Phone/Fax

Practice location:
  • Phone: 404-464-8169
  • Fax: 404-921-9577
Mailing address:
  • Phone: 404-464-8169
  • Fax: 404-921-9577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number1366405037
License Number StateGA

VIII. Authorized Official

Name: DERRON SIMON
Title or Position: CHIEF MEDICAL DIRECTOR
Credential: MD
Phone: 804-441-5040