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General NPI Number Information
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NPI Number | 1629169164
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Entity Type | Organization
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Legal Business Name | LOCUST GROVE FAMILY MEDICINE
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Dates
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Enumeration Date | 09/28/2006
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Last Update Date | 03/14/2016
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Provider Practice Location Address
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Address Line | 3778 HIGHWAY 42
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City | LOCUST GROVE
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State | GA
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Zip | 30248-3632
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Country | US
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Telephone | 678-610-6649
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Fax | 678-610-6025
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Provider Business Mailing Address
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Address Line | 3778 HIGHWAY 42
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City | LOCUST GROVE
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State | GA
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Zip | 30248-3632
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Country | US
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Telephone | 678-610-6649
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Fax | 678-610-6025
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Authorized Official
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Title or Position | OWNER
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Name | DR. NIMISHA J TRIVEDI
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Credential | MD
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Telephone | 678-610-6649
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 053715
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 332900000X
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Taxonomy Name | Non-Pharmacy Dispensing Site
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License Number | 053715
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License Number State | GA
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