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General NPI Number Information
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NPI Number | 1346595204
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Entity Type | Organization
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Legal Business Name | COVENANT FAMILY MEDICINE GMG LLC
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Dates
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Enumeration Date | 07/17/2012
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Last Update Date | 08/23/2013
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Provider Practice Location Address
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Address Line | 2098 TERON TRCE SUITE 150
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City | DACULA
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State | GA
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Zip | 30019-1663
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Country | US
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Telephone | 678-730-1620
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Fax |
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Provider Business Mailing Address
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Address Line | 2069 TERON TRCE SUITE 100
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City | DACULA
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State | GA
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Zip | 30019-1665
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Country | US
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Telephone | 678-730-1620
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. STEVEN A RUBIN
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Credential |
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Telephone | 470-325-0150
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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 |
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License Number State |
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