Healthcare Provider Details

I. General information

NPI: 1912366931
Provider Name (Legal Business Name): RIVER PARC INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 RIVER GREEN PKWY STE 140
DULUTH GA
30096-8333
US

IV. Provider business mailing address

4855 RIVER GREEN PKWY STE 140
DULUTH GA
30096-8333
US

V. Phone/Fax

Practice location:
  • Phone: 678-417-0077
  • Fax: 678-417-0337
Mailing address:
  • Phone: 678-417-0077
  • Fax: 678-417-0337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberRN193179
License Number StateGA

VIII. Authorized Official

Name: YOUNG KANG
Title or Position: MD
Credential: M.D
Phone: 678-417-0077