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General NPI Number Information
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NPI Number | 1649703836
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Entity Type | Organization
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Legal Business Name | MID PHYSICIAN NETWORK (WV), PLLC
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Dates
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Enumeration Date | 04/05/2017
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Last Update Date | 04/05/2017
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Provider Practice Location Address
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Address Line | 5665 NEW NORTHSIDE DR SUITE 520
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City | ATLANTA
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State | GA
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Zip | 30328-5831
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Country | US
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Telephone | 678-491-2804
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Fax |
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Provider Business Mailing Address
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Address Line | 5665 NEW NORTHSIDE DR SUITE 520
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City | ATLANTA
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State | GA
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Zip | 30328-5831
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | ADRIAN DAVIS
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Credential |
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Telephone | 678-491-2804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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