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General NPI Number Information
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NPI Number | 1285672220
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Entity Type | Organization
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Legal Business Name | NORTHLAKE PHYSICIAN PRACTICE NETWORK INC
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Dates
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Enumeration Date | 06/03/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1459 MONTREAL RD 408
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City | TUCKER
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State | GA
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Zip | 30084-6900
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Country | US
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Telephone | 770-938-3440
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Fax | 770-938-3443
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Provider Business Mailing Address
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Address Line | 1459 MONTREAL RD 408
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City | TUCKER
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State | GA
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Zip | 30084-6900
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Country | US
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Telephone | 770-938-3440
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Fax | 770-938-3443
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Authorized Official
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Title or Position | VP
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Name | MARK PICKETT
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Credential |
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Telephone | 678-762-5037
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086X0206X
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Taxonomy Name | Surgical Oncology Physician
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License Number |
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License Number State |
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