=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417571175
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INFUSIMED, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2020
-----------------------------------------------------
Last Update Date | 05/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2193 CASCADE RD SW
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30311-2862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-884-9691
-----------------------------------------------------
Fax | 404-907-4052
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3939 LAVISTA RD # E-310
-----------------------------------------------------
City | TUCKER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30084-5162
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-884-9691
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ZANDRAETTA L TIMS-COOK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 844-884-9691
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------