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General NPI Number Information
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NPI Number | 1710058938
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Entity Type | Organization
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Legal Business Name | BETHESDA FAMILY PRACTICE ASSOC
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Dates
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Enumeration Date | 11/10/2006
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Last Update Date | 07/13/2010
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Provider Practice Location Address
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Address Line | 4039 ATLANTA ST
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City | POWDER SPRINGS
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State | GA
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Zip | 30127-2666
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Country | US
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Telephone | 770-943-3139
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Fax | 770-439-5501
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Provider Business Mailing Address
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Address Line | 4039 ATLANTA ST
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City | POWDER SPRINGS
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State | GA
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Zip | 30127-2666
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Country | US
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Telephone | 770-943-3139
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Fax | 770-439-5501
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. JACK T SALTZ
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Credential | M.D.
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Telephone | 770-943-3139
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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 | 031115
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License Number State | GA
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