Healthcare Provider Details

I. General information

NPI: 1003426628
Provider Name (Legal Business Name): REAGAN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2020
Last Update Date: 08/07/2020
Certification Date: 08/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 FRIENDSHIP RD STE 110
BRASELTON GA
30517-5609
US

IV. Provider business mailing address

2878 FIVE FORKS TRICKUM RD STE 2A
LAWRENCEVILLE GA
30044-5896
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-8700
  • Fax:
Mailing address:
  • Phone: 678-344-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SATISH B PODDAR
Title or Position: MD
Credential:
Phone: 678-344-8700