=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093304164
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSALIND MEDICAL CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2021
-----------------------------------------------------
Last Update Date | 04/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1762 ROSALIND DR NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30329-2538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-382-6883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1762 ROSALIND DR NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30329-2538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-382-6883
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | CORBY BARKHAUS
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 404-382-6883
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------