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General NPI Number Information
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NPI Number | 1225133796
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Entity Type | Organization
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Legal Business Name | WILLOW CREEK FAMILY MEDICINE, PC
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 12/02/2013
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Provider Practice Location Address
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Address Line | 11685 ALPHARETTA HWY STE 300
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City | ROSWELL
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State | GA
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Zip | 30076-4913
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Country | US
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Telephone | 678-325-6611
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Fax | 678-325-6616
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Provider Business Mailing Address
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Address Line | 11685 ALPHARETTA HWY STE 300
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City | ROSWELL
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State | GA
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Zip | 30076-4913
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Country | US
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Telephone | 678-325-6611
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Fax | 678-325-6616
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | LISA M. ROSA-RE
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Credential | M.D.
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Telephone | 678-325-6611
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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 | 029768
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License Number State | GA
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