Healthcare Provider Details

I. General information

NPI: 1326340829
Provider Name (Legal Business Name): SMOKERISE FAMILY MEDICAL ASSOC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2010
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 LILBURN STONE MOUNTAIN RD STE 100
STONE MOUNTAIN GA
30087-1857
US

IV. Provider business mailing address

1505 LILBURN STONE MOUNTAIN RD STE 100
STONE MOUNTAIN GA
30087-1857
US

V. Phone/Fax

Practice location:
  • Phone: 770-469-1711
  • Fax: 770-469-1837
Mailing address:
  • Phone: 770-469-1711
  • Fax: 770-469-1837

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0033273
License Number StateGA

VIII. Authorized Official

Name: MR. MICHAEL LESLEY BARON
Title or Position: FAMILY PHYSICIAN/PRESIDENT
Credential: D.O.
Phone: 770-469-1711