Healthcare Provider Details

I. General information

NPI: 1225585037
Provider Name (Legal Business Name): FAMILY MEDICAL THERAPIES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 02/09/2020
Certification Date: 02/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 STUART RD STE 88
FT OGLETHORPE GA
30742-4047
US

IV. Provider business mailing address

6 ROCK CREST DR
SIGNAL MOUNTAIN TN
37377-2302
US

V. Phone/Fax

Practice location:
  • Phone: 423-521-5404
  • Fax: 423-910-0379
Mailing address:
  • Phone: 423-521-5404
  • Fax: 706-406-2922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number70270
License Number StateGA

VIII. Authorized Official

Name: PAUL MIRANDA
Title or Position: OWNER
Credential: MD
Phone: 423-243-8196