Provider Demographics
NPI:1003058165
Name:EXTREME MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:EXTREME MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DIDIER
Authorized Official - Middle Name:
Authorized Official - Last Name:GUTIERREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-237-6363
Mailing Address - Street 1:2484 BRIARCLIFF RD NE
Mailing Address - Street 2:SUITE 22-353
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-3011
Mailing Address - Country:US
Mailing Address - Phone:678-237-6363
Mailing Address - Fax:
Practice Address - Street 1:2484 BRIARCLIFF RD NE
Practice Address - Street 2:SUITE 22-353
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-3011
Practice Address - Country:US
Practice Address - Phone:678-237-6363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty