MEDICARE: ST. JUDE'S INTERNAL MEDICINE, 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

General Provider Information

NPI Number	:	1477863579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JUDE'S INTERNAL MEDICINE, LLC

Provider Business Mailing Address
First Line	:	1198 BUCKHEAD XING
Second Line	:	STE C
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-4257
Country	:	US
Telephone Number	:	678-324-7406
Fax Number	:	770-627-4322

Provider Business Practice Location Address
First Line	:	1198 BUCKHEAD XING
Second Line	:	STE C
City	:	WOODSTOCK
State	:	GA
Zip	:	30189-4257
Country	:	US
Telephone Number	:	678-324-7406
Fax Number	:	770-627-4322

Authorized Official
Title or Position	:	PROVIDER
Name	:	OSBORNE F D'SOUZA
Credential	:	MD
Telephone Number	:	678-324-7406

Provider Enumeration Date	:	10/07/2010
Last Update Date	:	05/08/2014

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