Provider Demographics
NPI:1043680341
Name:MILTON MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:MILTON MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAVITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-827-9157
Mailing Address - Street 1:11585 JONES BRIDGE RD
Mailing Address - Street 2:420-215
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8129
Mailing Address - Country:US
Mailing Address - Phone:678-827-9157
Mailing Address - Fax:470-299-6262
Practice Address - Street 1:735 N MAIN ST
Practice Address - Street 2:1100
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-2405
Practice Address - Country:US
Practice Address - Phone:678-827-9157
Practice Address - Fax:470-299-6262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046324261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003173272AMedicaid
202G703682Medicare PIN