=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184703779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY MEDICAL CENTER P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2006
-----------------------------------------------------
Last Update Date | 07/16/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5615 OLD NATIONAL HWY STE D
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30349-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-997-2900
-----------------------------------------------------
Fax | 404-767-7053
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5615 OLD NATIONAL HWY STE D
-----------------------------------------------------
City | COLLEGE PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30349-3817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-997-2900
-----------------------------------------------------
Fax | 404-767-7053
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. SALLU MOHAMED JABATI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 770-997-2900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 058527
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------