Healthcare Provider Details

I. General information

NPI: 1619166717
Provider Name (Legal Business Name): GWINNETT FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 02/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 GRAYSON HWY
LAWRENCEVILLE GA
30045-6332
US

IV. Provider business mailing address

510 GRAYSON HWY
LAWRENCEVILLE GA
30045-6332
US

V. Phone/Fax

Practice location:
  • Phone: 770-995-9565
  • Fax:
Mailing address:
  • Phone: 770-995-9565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number52073
License Number StateGA

VIII. Authorized Official

Name: SYED A ALI
Title or Position: PRACTICE MANAGER
Credential:
Phone: 770-910-2377