Provider Demographics
NPI:1083884803
Name:RICHARD W KING JR
Entity Type:Organization
Organization Name:RICHARD W KING JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REITA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-303-3200
Mailing Address - Street 1:2550 WINDY HILL RD SE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8665
Mailing Address - Country:US
Mailing Address - Phone:678-303-3200
Mailing Address - Fax:678-303-3205
Practice Address - Street 1:2550 WINDY HILL RD SE
Practice Address - Street 2:SUITE 110
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-8665
Practice Address - Country:US
Practice Address - Phone:678-303-3200
Practice Address - Fax:678-303-3205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA31517207PE0005X
GA021872208100000X
GAGA021872225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD45868Medicare UPIN
GAGRP3663Medicare PIN