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General NPI Number Information
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NPI Number | 1710286414
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Entity Type | Organization
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Legal Business Name | NORTHLAKE INTERNAL MEDICINE
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Dates
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Enumeration Date | 03/21/2011
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Last Update Date | 03/21/2011
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Provider Practice Location Address
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Address Line | 2175 NORTHLAKE PKWY ST 142,BLDG 4
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City | TUCKER
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State | GA
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Zip | 30084-4163
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Country | US
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Telephone | 770-496-2929
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Fax | 770-496-2930
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Provider Business Mailing Address
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Address Line | 2175 NORTHLAKE PKWY ST 142,BLDG 4
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City | TUCKER
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State | GA
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Zip | 30084-4163
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Country | US
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Telephone | 770-496-2929
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Fax | 770-496-2930
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN WILLIAM BUDELL
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Credential | M.D,
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Telephone | 770-496-2929
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 017369
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License Number State | GA
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