=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922311265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIRGINIA INPATIENT MEDICINE ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2010
-----------------------------------------------------
Last Update Date | 07/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5901 PEACHTREE DUNWOODY RD NE SUITE C-350
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-5382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-441-8500
-----------------------------------------------------
Fax | 678-397-0065
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 96368
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73143-6368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-441-8500
-----------------------------------------------------
Fax | 678-397-0065
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT-CHIEF OPERATING OFFICIER
-----------------------------------------------------
Name | DR. TALBOT GREEN MCCORMICK III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 678-441-8500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------