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General NPI Number Information
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NPI Number | 1467617043
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Entity Type | Organization
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Legal Business Name | INTERNAL MEDICINE ASSOCIATES OF LAWRENCEVILLE PC
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Dates
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Enumeration Date | 07/23/2008
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Last Update Date | 03/10/2011
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Provider Practice Location Address
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Address Line | 748 OLD NORCROSS RD SUITE 150
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-3393
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Country | US
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Telephone | 770-338-5070
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Fax | 770-338-2568
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Provider Business Mailing Address
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Address Line | 748 OLD NORCROSS RD SUITE 150
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City | LAWRENCEVILLE
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State | GA
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Zip | 30046-3393
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Country | US
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Telephone | 770-338-5070
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Fax | 770-338-2568
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. AGBOR N EGBEWATT
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Credential | M.D
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Telephone | 770-338-5070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 038744
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License Number State | GA
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