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General NPI Number Information
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NPI Number | 1720272412
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Entity Type | Organization
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Legal Business Name | JOHNS CREEK FAMILY MEDICINE LLC
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Dates
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Enumeration Date | 09/05/2007
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Last Update Date | 10/15/2012
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Provider Practice Location Address
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Address Line | 4365 JOHNS CREEK PKWY SUITE 430
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City | SUWANEE
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State | GA
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Zip | 30024-6089
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Country | US
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Telephone | 678-474-0040
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Fax | 678-474-0095
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Provider Business Mailing Address
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Address Line | 4365 JOHNS CREEK PKWY SUITE 430
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City | SUWANEE
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State | GA
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Zip | 30024-6089
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Country | US
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Telephone | 678-474-0040
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Fax | 678-474-0095
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Authorized Official
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Title or Position | MEMBER
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Name | JAMES L ROTH
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Credential | MD
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Telephone | 678-474-0040
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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 | 046525
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License Number State | GA
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