Healthcare Provider Details

I. General information

NPI: 1841404589
Provider Name (Legal Business Name): PEACE HEALTH FAMILY MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 ROBERTS DR SUTIE A
RIVERDALE GA
30274-2959
US

IV. Provider business mailing address

653 ROBERTS DR
RIVERDALE GA
30274-2959
US

V. Phone/Fax

Practice location:
  • Phone: 770-907-8400
  • Fax: 770-907-8430
Mailing address:
  • Phone: 770-907-8400
  • Fax: 770-907-8430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KAREN SCOTT
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 770-907-8400