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General NPI Number Information
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NPI Number | 1124596069
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Entity Type | Organization
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Legal Business Name | LONGEVITY MEDICAL CENTER, PC
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Dates
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Enumeration Date | 11/08/2018
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Last Update Date | 11/08/2018
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Provider Practice Location Address
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Address Line | 4646 N SHALLOWFORD RD STE 300
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City | ATLANTA
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State | GA
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Zip | 30338-6308
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Country | US
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Telephone | 678-736-6383
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Fax | 678-280-6761
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Provider Business Mailing Address
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Address Line | 1551 DUNWOODY VILLAGE PKWY UNIT 888426
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City | ATLANTA
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State | GA
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Zip | 30356-0115
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Country | US
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Telephone | 678-736-6383
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Fax | 678-280-6761
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Authorized Official
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Title or Position | DOO
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Name | SAIRA SULTAN
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Credential |
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Telephone | 770-676-6000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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