=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578569323
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STONE MOUNTAIN IMMEDIATE MEDICAL CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2005
-----------------------------------------------------
Last Update Date | 11/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 833 N HAIRSTON RD
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-879-5553
-----------------------------------------------------
Fax | 770-879-5592
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 833 N HAIRSTON RD
-----------------------------------------------------
City | STONE MOUNTAIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30083-3423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-879-5553
-----------------------------------------------------
Fax | 770-879-5592
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MGR
-----------------------------------------------------
Name | MS. DORIS LYNN DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 770-879-5553
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 038143
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------