Provider Demographics
NPI:1063833267
Name:ID GROUP OF ATLANTA
Entity Type:Organization
Organization Name:ID GROUP OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:OUDERKIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-588-4680
Mailing Address - Street 1:735 PIEDMONT AVENUE, NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308
Mailing Address - Country:US
Mailing Address - Phone:404-588-4680
Mailing Address - Fax:
Practice Address - Street 1:735 PIEDMONT AVENUE, NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308
Practice Address - Country:US
Practice Address - Phone:404-588-4680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-16
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049992332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000926318AMedicaid
GA000926318AMedicaid