Healthcare Provider Details

I. General information

NPI: 1184990202
Provider Name (Legal Business Name): GEORGIA EM-I MEDICAL SERVICE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2012
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MEDICAL WAY
SNELLVILLE GA
30078-2195
US

IV. Provider business mailing address

18167 US HIGHWAY 19 NORTH SUITE 650
CLEARWATER FL
33764-3528
US

V. Phone/Fax

Practice location:
  • Phone: 770-979-0200
  • Fax:
Mailing address:
  • Phone: 800-507-8874
  • Fax: 727-536-2896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: KAREN VAUGHN
Title or Position: OFFICER
Credential:
Phone: 973-251-1132