Healthcare Provider Details

I. General information

NPI: 1104592484
Provider Name (Legal Business Name): STANDARDCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 HARRIS WAY
BROOKHAVEN GA
30319-3817
US

IV. Provider business mailing address

1314 HARRIS WAY
BROOKHAVEN GA
30319-3817
US

V. Phone/Fax

Practice location:
  • Phone: 718-710-9796
  • Fax:
Mailing address:
  • Phone: 718-710-9796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: BABATUNDE EDUN
Title or Position: OWNER
Credential: MD
Phone: 718-710-9796