Healthcare Provider Details

I. General information

NPI: 1871566885
Provider Name (Legal Business Name): KAREN M BRANCEWICZ PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 05/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 YORKTOWN STE 100
FAYETTEVILLE GA
30214
US

IV. Provider business mailing address

P.O. BOX 10231
ATLANTA GA
30368
US

V. Phone/Fax

Practice location:
  • Phone: 770-460-4075
  • Fax: 770-460-4319
Mailing address:
  • Phone: 770-460-4075
  • Fax: 770-460-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA000841L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number006063
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: