Healthcare Provider Details

I. General information

NPI: 1659414175
Provider Name (Legal Business Name): STILLWELL MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 LOGAN DR UNIT 1596
LOGANVILLE GA
30052-9516
US

IV. Provider business mailing address

4160 LOGAN DR #1596
LOGANVILLE GA
30052
US

V. Phone/Fax

Practice location:
  • Phone: 678-557-0207
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3135
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name: LATONDRA DENISE BARKER
Title or Position: MANAGER
Credential:
Phone: 678-557-0207