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General NPI Number Information
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NPI Number | 1598857229
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Entity Type | Organization
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Legal Business Name | LEEWAY MEDICAL GROUP, P.C.
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Dates
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Enumeration Date | 09/29/2006
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Last Update Date | 11/20/2007
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Provider Practice Location Address
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Address Line | 8311 OFFICE PARK DR
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-6935
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Country | US
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Telephone | 770-577-6121
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Fax | 770-577-1152
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Provider Business Mailing Address
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Address Line | 1665 WATERWAY XING SW
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City | ATLANTA
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State | GA
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Zip | 30331-8060
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Country | US
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Telephone | 770-577-6121
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Fax | 770-577-1152
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARVIN LEE III MD
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Credential | M.D.
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Telephone | 770-577-6121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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