=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972929685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WITHINME MD, ATLANTA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2014
-----------------------------------------------------
Last Update Date | 03/06/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 604 GLEN IRIS DR NE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-464-8169
-----------------------------------------------------
Fax | 404-921-9577
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 604 GLEN IRIS DR NE 5275 LEE HIGHWAY #201, ARLINGTON, VIRGINIA 22207
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30308-2717
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-464-8169
-----------------------------------------------------
Fax | 404-921-9577
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL DIRECTOR
-----------------------------------------------------
Name | DERRON SIMON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 804-441-5040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 1366405037
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------