=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598172769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A & A FAMILY MEDICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2014
-----------------------------------------------------
Last Update Date | 07/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 47 WHITEGRASS CT
-----------------------------------------------------
City | GRAYSON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30017-4180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-296-9193
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 47 WHITEGRASS CT
-----------------------------------------------------
City | GRAYSON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30017-4180
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-296-9193
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. PAMELLA CHARLES-PRYCE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 770-296-9193
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 058155
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------