MEDICARE: PMC HEALTHCARE AND DIAGNOSTICS 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	207Q00000X	Family Medicine Physician
2	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1700183357
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PMC HEALTHCARE AND DIAGNOSTICS PC

Provider Business Mailing Address
First Line	:	2090 DUNWOODY CIRCLE CLUB DRIVE
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30350
Country	:	US
Telephone Number	:	770-676-6000
Fax Number	:	770-392-9805

Provider Business Practice Location Address
First Line	:	4646 N SHALLOWFORD RD
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30338-6308
Country	:	US
Telephone Number	:	770-676-6000
Fax Number	:	770-392-9805

Authorized Official
Title or Position	:	BILLING SUPERVISOR
Name	:	MRS. MARY LEACH
Credential	:
Telephone Number	:	770-676-6000

Provider Enumeration Date	:	02/17/2011
Last Update Date	:	05/18/2011

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