MEDICARE: MOREHOUSE MEDICAL ASSOCIATE

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	261QP2300X	Primary Care Clinic/Center	51	GA

General Provider Information

NPI Number	:	1659401487
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOREHOUSE MEDICAL ASSOCIATE

Provider Business Mailing Address
First Line	:	720 WESTVIEW DR SW STE 100
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30310-1458
Country	:	US
Telephone Number	:	404-756-5752
Fax Number	:	404-756-5274

Provider Business Practice Location Address
First Line	:	1513 CLEVELAND AVE
Second Line	:	500
City	:	EAST POINT
State	:	GA
Zip	:	30344-6947
Country	:	US
Telephone Number	:	404-752-1000
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	JASMINE S BAJNATH
Credential	:
Telephone Number	:	404-756-5752

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	03/28/2018

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