Healthcare Provider Details

I. General information

NPI: 1457715229
Provider Name (Legal Business Name): SWIFT FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5185 OLD NATIONAL HWY
COLLEGE PARK GA
30349-3244
US

IV. Provider business mailing address

5185 OLD NATIONAL HWY
COLLEGE PARK GA
30349-3244
US

V. Phone/Fax

Practice location:
  • Phone: 404-763-9300
  • Fax:
Mailing address:
  • Phone: 404-763-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number63084
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number63084
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number63084
License Number StateGA

VIII. Authorized Official

Name: MS. ANGELA COPELAND
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 770-778-2994