=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538022975
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRUPO MEDICO DE GEORGIA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2025
-----------------------------------------------------
Last Update Date | 12/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2721 S COBB DR SE
-----------------------------------------------------
City | SMYRNA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30080-3240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-444-9494
-----------------------------------------------------
Fax | 770-436-4656
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4225 S LEE ST STE B
-----------------------------------------------------
City | BUFORD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30518-3872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-559-3555
-----------------------------------------------------
Fax | 678-730-7777
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | EDDY LAJARA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-559-3555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------