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General NPI Number Information
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NPI Number | 1447688163
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Entity Type | Organization
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Legal Business Name | ATLANTA INTEGRATED MEDICAL HEALTH CENTER
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Dates
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Enumeration Date | 10/15/2013
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Last Update Date | 10/15/2013
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Provider Practice Location Address
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Address Line | 626 PARKWAY DR NE
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City | ATLANTA
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State | GA
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Zip | 30308-2614
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Country | US
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Telephone | 678-705-8261
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Fax | 678-705-8361
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Provider Business Mailing Address
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Address Line | 626 PARKWAY DR NE
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City | ATLANTA
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State | GA
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Zip | 30308-2614
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Country | US
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Telephone | 678-705-8261
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Fax | 678-705-8361
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Authorized Official
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Title or Position | MANAGER
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Name | MR. HAMP MATHIS
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Credential |
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Telephone | 678-705-8261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305S00000X
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Taxonomy Name | Point of Service
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License Number | 159564LGB
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 159564LGB
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License Number State | GA
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