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General NPI Number Information
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NPI Number | 1669502480
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Entity Type | Organization
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Legal Business Name | EAST COBB MEDICAL CLINIC, LLC
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Dates
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Enumeration Date | 03/07/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3750 PALLADIAN VILLAGE DR STE 400
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City | MARIETTA
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State | GA
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Zip | 30066-8200
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Country | US
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Telephone | 770-924-2252
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Fax |
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Provider Business Mailing Address
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Address Line | 3750 PALLADIAN VILLAGE DR STE 400
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City | MARIETTA
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State | GA
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Zip | 30066-8200
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Country | US
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Telephone | 770-924-2252
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Fax |
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Authorized Official
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Title or Position | CREDENTIALLING MANAGER
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Name | JAMES K IRUNGU
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Credential |
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Telephone | 770-924-2252
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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 | 049588
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License Number State | GA
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