Healthcare Provider Details

I. General information

NPI: 1710286414
Provider Name (Legal Business Name): NORTHLAKE INTERNAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2011
Last Update Date: 03/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2175 NORTHLAKE PKWY ST 142,BLDG 4
TUCKER GA
30084-4163
US

IV. Provider business mailing address

2175 NORTHLAKE PKWY ST 142,BLDG 4
TUCKER GA
30084-4163
US

V. Phone/Fax

Practice location:
  • Phone: 770-496-2929
  • Fax: 770-496-2930
Mailing address:
  • Phone: 770-496-2929
  • Fax: 770-496-2930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number017369
License Number StateGA

VIII. Authorized Official

Name: DR. JOHN WILLIAM BUDELL
Title or Position: OWNER
Credential: M.D,
Phone: 770-496-2929