Healthcare Provider Details

I. General information

NPI: 1235446394
Provider Name (Legal Business Name): INTOWN FAMILY PRACTICE & SPORTS MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 09/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 BOULEVARD AVE NE SUITE 640
ATLANTA GA
30312-4212
US

IV. Provider business mailing address

285 BOULEVARD AVE NE SUITE 640
ATLANTA GA
30312-4212
US

V. Phone/Fax

Practice location:
  • Phone: 404-577-7800
  • Fax: 404-577-7810
Mailing address:
  • Phone: 404-577-7800
  • Fax: 404-577-7810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number20330
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number038777
License Number StateGA

VIII. Authorized Official

Name: LAWRENCE LEO GOLUSINSKI JR.
Title or Position: OWNER
Credential: M.D.
Phone: 404-577-7800