Provider Demographics
NPI:1053649608
Name:RONALD D PATRICK MD LLC
Entity Type:Organization
Organization Name:RONALD D PATRICK MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:D
Authorized Official - Last Name:PATRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-331-5206
Mailing Address - Street 1:366 RACETRACK RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-1022
Mailing Address - Country:US
Mailing Address - Phone:706-331-5206
Mailing Address - Fax:
Practice Address - Street 1:366 RACETRACK RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-1022
Practice Address - Country:US
Practice Address - Phone:706-331-5206
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036427208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA437742618AMedicaid
GA00525819CMedicaid
GA02BDGQZOtherMEDICARE PROVIDER
GAF44324Medicare UPIN