Healthcare Provider Details

I. General information

NPI: 1356530174
Provider Name (Legal Business Name): MEDICAL PRACTICE OF JAMES L. FISHER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 10/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 LACY ST NW SUITE A
MARIETTA GA
30060-1154
US

IV. Provider business mailing address

140 LACY ST NW SUITE A
MARIETTA GA
30060-1154
US

V. Phone/Fax

Practice location:
  • Phone: 770-422-1985
  • Fax: 770-422-2814
Mailing address:
  • Phone: 770-422-1985
  • Fax: 770-422-2814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number025749
License Number StateGA

VIII. Authorized Official

Name: JAMES L FISHER
Title or Position: OWNER
Credential:
Phone: 770-422-1985