MEDICARE: MAYUGA FAMILY MEDICINE 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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1972203735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAYUGA FAMILY MEDICINE LLC

Provider Business Mailing Address
First Line	:	1575 HARVEST LN
Second Line	:
City	:	ALPHARETTA
State	:	GA
Zip	:	30004-6741
Country	:	US
Telephone Number	:	770-742-9326
Fax Number	:	862-298-0871

Provider Business Practice Location Address
First Line	:	236B STOCKBRIDGE RD
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30236-3629
Country	:	US
Telephone Number	:	770-742-9326
Fax Number	:	862-298-0871

Authorized Official
Title or Position	:	OWNER
Name	:	TOM JOHN ALBUNIAN MAYUGA
Credential	:	DO
Telephone Number	:	770-742-9326

Provider Enumeration Date	:	03/09/2023
Last Update Date	:	03/13/2023

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