MEDICARE: AMARC MEDICAL & RESEARCH CLINIC

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	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1497951081
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMARC MEDICAL & RESEARCH CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 767
Second Line	:
City	:	FAIRBURN
State	:	GA
Zip	:	30213-0767
Country	:	US
Telephone Number	:	404-838-0904
Fax Number	:	770-446-2686

Provider Business Practice Location Address
First Line	:	1309 LAKEWOOD AVE SE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30315-2312
Country	:	US
Telephone Number	:	404-838-0904
Fax Number	:	770-446-2686

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	BONA ILONZO
Credential	:
Telephone Number	:	404-838-0904

Provider Enumeration Date	:	06/21/2007
Last Update Date	:	08/22/2020

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