=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265573141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIANS IMMEDIATE MED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 02/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3425 BUFORD DRIVE SUITE 200
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-546-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3425 BUFORD DRIVE SUITE 200
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-546-0200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BRANCH MANAGER
-----------------------------------------------------
Name | NICOLE JORDAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-546-0200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------