=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568628618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY MEDICAL CLINIC OF SNELLVILLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2008
-----------------------------------------------------
Last Update Date | 06/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3891 STONE MOUNTAIN HWY
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-972-4764
-----------------------------------------------------
Fax | 770-972-4164
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3891 STONE MOUNTAIN HWY
-----------------------------------------------------
City | SNELLVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30039-3932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-972-4764
-----------------------------------------------------
Fax | 770-972-4164
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | GORDON GLENN FREEMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 770-972-4764
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 023958
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------