MEDICARE: CHAMBLEE MEDICAL 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	332900000X	Non-Pharmacy Dispensing Site	026895	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1154284	OTHER		OTHER ID NUMBER
2	1154284	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER

General Provider Information

NPI Number	:	1609820745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAMBLEE MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 80042
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30366-0042
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3739 CHAMBLEE DUNWOODY RD
Second Line	:
City	:	CHAMBLEE
State	:	GA
Zip	:	30341-2062
Country	:	US
Telephone Number	:	770-458-0025
Fax Number	:	770-458-0807

Authorized Official
Title or Position	:	OWNER
Name	:	SOREN THOMAS
Credential	:
Telephone Number	:	770-458-0025

Provider Enumeration Date	:	05/22/2006
Last Update Date	:	02/25/2008

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Directions to “CHAMBLEE MEDICAL CLINIC ” Practice Location

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