Provider Demographics
NPI:1023362191
Name:BRIDGEMILL HEALTH GROUP LLC
Entity Type:Organization
Organization Name:BRIDGEMILL HEALTH GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:DEPOL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-880-6118
Mailing Address - Street 1:3542 SIXES RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-9124
Mailing Address - Country:US
Mailing Address - Phone:678-880-6118
Mailing Address - Fax:770-720-1389
Practice Address - Street 1:3542 SIXES RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-9124
Practice Address - Country:US
Practice Address - Phone:678-880-6118
Practice Address - Fax:770-720-1389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO07708111N00000X
GA26936207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty