=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154703478
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGIONAL OCCUPATIONAL MEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2015
-----------------------------------------------------
Last Update Date | 06/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1368 SOUTHLAKE PLAZA DR
-----------------------------------------------------
City | MORROW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30260-1756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-709-0634
-----------------------------------------------------
Fax | 404-492-0777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1368 SOUTHLAKE PLAZA DR
-----------------------------------------------------
City | MORROW
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30260-1756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-709-0634
-----------------------------------------------------
Fax | 404-492-0777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. CARMEN BAKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-709-0634
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------