1720272412 NPI number — JOHNS CREEK FAMILY MEDICINE LLC

Table of content: (NPI 1720272412)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720272412 NPI number — JOHNS CREEK FAMILY MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOHNS CREEK FAMILY MEDICINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720272412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4365 JOHNS CREEK PKWY
Provider Second Line Business Mailing Address:
SUITE 430
Provider Business Mailing Address City Name:
SUWANEE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30024-6089
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-474-0040
Provider Business Mailing Address Fax Number:
678-474-0095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4365 JOHNS CREEK PKWY
Provider Second Line Business Practice Location Address:
SUITE 430
Provider Business Practice Location Address City Name:
SUWANEE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30024-6089
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-474-0040
Provider Business Practice Location Address Fax Number:
678-474-0095
Provider Enumeration Date:
09/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ROTH
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
678-474-0040

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  046525 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DB1574 . This is a "RAILROAD MEDICARE GROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: GRP4691 . This is a "MEDICARE GROUP NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000971308A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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