Healthcare Provider Details

I. General information

NPI: 1437194156
Provider Name (Legal Business Name): PEACHTREE IMMEDIATE CARE FP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3827 JIMMY LEE SMITH PKWY
HIRAM GA
30141-2630
US

IV. Provider business mailing address

590 LANIER AVE W
FAYETTEVILLE GA
30214-1504
US

V. Phone/Fax

Practice location:
  • Phone: 770-222-8900
  • Fax: 770-222-2757
Mailing address:
  • Phone: 678-688-9685
  • Fax: 770-626-3791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHANDI FAULK
Title or Position: VICE PRESIDENT, BILLING OPERATIONS
Credential:
Phone: 678-679-6471