MEDICARE: YOURTOWNDOCTOR LLC

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

General Provider Information

NPI Number	:	1750041075
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOURTOWNDOCTOR LLC

Provider Business Mailing Address
First Line	:	2902 PLANTERS MILL DR
Second Line	:
City	:	DACULA
State	:	GA
Zip	:	30019-1680
Country	:	US
Telephone Number	:	478-361-6055
Fax Number	:

Provider Business Practice Location Address
First Line	:	3665 SWIFTWATER PARK DR STE 307
Second Line	:
City	:	SUWANEE
State	:	GA
Zip	:	30024-7179
Country	:	US
Telephone Number	:	478-361-6055
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KATHERINE WIEGMAN
Credential	:	MD
Telephone Number	:	478-361-6055

Provider Enumeration Date	:	12/28/2021
Last Update Date	:	12/28/2021

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Directions to “YOURTOWNDOCTOR LLC ” Practice Location

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