=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487397105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRISM MEDICAL GROUP ,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2022
-----------------------------------------------------
Last Update Date | 04/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1343 TERRELL MILL RD SE STE 232
-----------------------------------------------------
City | MARIETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30067-9472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-814-4634
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2381 RED HIBISCUS CT
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-8019
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-844-8334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL POMPEY
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 404-844-8334
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------