Provider Demographics
NPI:1003174624
Name:ATLANTA INTERNAL MEDICINE AND PSYCHIATRIC CARE
Entity Type:Organization
Organization Name:ATLANTA INTERNAL MEDICINE AND PSYCHIATRIC CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:LUNCEFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-396-0232
Mailing Address - Street 1:4895 GUILFORD FOREST DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8373
Mailing Address - Country:US
Mailing Address - Phone:770-317-7300
Mailing Address - Fax:404-669-7574
Practice Address - Street 1:6111 PEACHTREE DUNWOODY RD NE # C
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-6049
Practice Address - Country:US
Practice Address - Phone:770-313-7300
Practice Address - Fax:770-399-0007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0505842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAREF000549852Medicaid
GAREF000549852Medicaid