Provider Demographics
NPI:1073753299
Name:MONROE HMA PHYSICIAN MANAGEMENT LLC
Entity Type:Organization
Organization Name:MONROE HMA PHYSICIAN MANAGEMENT LLC
Other - Org Name:LOGANVILLE OB/GYN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRGILIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-207-7859
Mailing Address - Street 1:705 BREEDLOVE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2090
Mailing Address - Country:US
Mailing Address - Phone:770-266-0351
Mailing Address - Fax:770-266-0313
Practice Address - Street 1:3543 HIGHWAY 81
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4336
Practice Address - Country:US
Practice Address - Phone:770-913-8082
Practice Address - Fax:770-913-8085
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONROE HMA PHYSICIAN MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-27
Last Update Date:2009-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051832207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty