MEDICARE: PRINCETON LAKES INTERNAL MEDICINE

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	1538167119	GA
2	174400000X	Specialist	1689894883	GA

General Provider Information

NPI Number	:	1649454265
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRINCETON LAKES INTERNAL MEDICINE

Provider Business Mailing Address
First Line	:	3885 PRINCETON LAKES WAY SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-5589
Country	:	US
Telephone Number	:	404-344-0059
Fax Number	:	404-344-9195

Provider Business Practice Location Address
First Line	:	3885 PRINCETON LAKES WAY SW
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-5589
Country	:	US
Telephone Number	:	404-344-0059
Fax Number	:	404-344-9195

Authorized Official
Title or Position	:	MEDICAL BILLER
Name	:	MS. BRENDA WHITE
Credential	:
Telephone Number	:	678-637-9155

Provider Enumeration Date	:	12/18/2007
Last Update Date	:	12/18/2007

Similar Medicare Providers

1811989478 — LISA C PERRY-GILKES M.D.
Practice Location Address:

3885 PRINCETON LAKES WAY SW , SUITE 312A
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30331-5589

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Practice Location Address:

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1528114295 — PREMIER SOUTH MEDICAL GROUP, P.C.
Practice Location Address:

3885 PRINCETON LAKES WAY SW , SUITE 412
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30331-5589

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1881729820 — DR. JACQUES LENOEL GORDON DMD
Practice Location Address:

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1982818951 — METRO ATLANTA ACCESS CENTER LLC
Practice Location Address:

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1144480146 — SOUTHCARE PHYSICIANS GROUP OBSTETRICS & GYNECOLOGY
Practice Location Address:

3885 PRINCETON LAKES WAY SW , SUITE 412
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30331-5589

Practice Phone: 404-466-1006
Practice Fax:

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