MEDICARE: COVENANT MEDICAL CENTER 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	207R00000X	Internal Medicine Physician	058389	GA

General Provider Information

NPI Number	:	1770726721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COVENANT MEDICAL CENTER PC

Provider Business Mailing Address
First Line	:	3970 FIVE FORKS TRICKUM RD SW
Second Line	:	SUITE A
City	:	LILBURN
State	:	GA
Zip	:	30047-2339
Country	:	US
Telephone Number	:	678-357-1282
Fax Number	:

Provider Business Practice Location Address
First Line	:	3970 FIVE FORKS TRICKUM RD SW
Second Line	:	SUITE A
City	:	LILBURN
State	:	GA
Zip	:	30047-2339
Country	:	US
Telephone Number	:	678-357-1282
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN/OWNER
Name	:	DR. CECILIA O BABALOLA
Credential	:	MD
Telephone Number	:	678-357-1282

Provider Enumeration Date	:	04/07/2009
Last Update Date	:	04/20/2010

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