MEDICARE: TRI COUNTY INTERNAL MEDICINE, PC

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	:	1528097318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRI COUNTY INTERNAL MEDICINE, PC

Provider Business Mailing Address
First Line	:	4720 NELSON BROGDON BLVD
Second Line	:
City	:	SUGAR HILL
State	:	GA
Zip	:	30518-3480
Country	:	US
Telephone Number	:	770-945-1990
Fax Number	:	678-745-4139

Provider Business Practice Location Address
First Line	:	4720 NELSON BROGDON BLVD
Second Line	:
City	:	SUGAR HILL
State	:	GA
Zip	:	30518-3480
Country	:	US
Telephone Number	:	770-945-1990
Fax Number	:	678-745-4139

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. SUSAN D COKER
Credential	:
Telephone Number	:	770-945-1990

Provider Enumeration Date	:	07/02/2006
Last Update Date	:	04/18/2008

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