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General NPI Number Information
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NPI Number | 1457521940
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Entity Type | Organization
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Legal Business Name | STANFORD MEDICAL GROUP, INC
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Dates
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Enumeration Date | 03/11/2008
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Last Update Date | 06/05/2008
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Provider Practice Location Address
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Address Line | 142 MITCHELL ST SW SUITE 200
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City | ATLANTA
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State | GA
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Zip | 30303-3439
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Country | US
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Telephone | 404-584-2105
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Fax | 404-584-2106
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Provider Business Mailing Address
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Address Line | 142 MITCHELL ST SW SUITE 200
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City | ATLANTA
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State | GA
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Zip | 30303-3439
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Country | US
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Telephone | 404-584-2105
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Fax | 404-584-2106
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Authorized Official
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Title or Position | OWNER
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Name | JEANETTE JUNCO PATINO
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Credential |
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Telephone | 786-837-1175
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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