MEDICARE: POLARIS MEDICAL GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist
2	174400000X	Specialist	052218	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366583577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	POLARIS MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	1136 CLEVELAND AVE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30344
Country	:	US
Telephone Number	:	404-766-8110
Fax Number	:	404-766-8106

Provider Business Practice Location Address
First Line	:	1136 CLEVELAND AVE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30344
Country	:	US
Telephone Number	:	404-766-8110
Fax Number	:	404-766-8106

Authorized Official
Title or Position	:	CFO
Name	:	DR. LISA C PERRY-GILKES
Credential	:	M.D.
Telephone Number	:	404-766-8110

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	04/03/2009

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Directions to “POLARIS MEDICAL GROUP LLC ” Practice Location

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