=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285193474
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1ST CHOICE TELEMEDICINE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2019
-----------------------------------------------------
Last Update Date | 05/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 ROCK QUARRY RD
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-722-5778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1500 ROCK QUARRY RD
-----------------------------------------------------
City | STOCKBRIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30281-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-722-5778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. BENNIE LEE BROWN JR.
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 229-395-1253
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------