MEDICARE: PROF. JOHN MARK LIDELL M.M.SC. , PA-C

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	363A00000X	Physician Assistant	002952	GA

General Provider Information

NPI Number	:	1962487538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PROF. JOHN MARK LIDELL M.M.SC. , PA-C

Provider Business Mailing Address
First Line	:	3576 HIGHWAY 138 SE
Second Line	:
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-7909
Country	:	US
Telephone Number	:	770-474-7448
Fax Number	:	770-474-7194

Provider Business Practice Location Address
First Line	:	101 REGENCY PARK DR STE 110
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-7076
Country	:	US
Telephone Number	:	404-996-0126
Fax Number	:	678-432-2626

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	10/27/2021

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