Provider Demographics
NPI:1093176778
Name:MIGUEL E. STUBBS, MD PC
Entity Type:Organization
Organization Name:MIGUEL E. STUBBS, MD PC
Other - Org Name:MIGUEL E. STUBBS, MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:ELHALCON
Authorized Official - Last Name:STUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PC
Authorized Official - Phone:404-803-5246
Mailing Address - Street 1:3154 ABBEY DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5467
Mailing Address - Country:US
Mailing Address - Phone:404-803-5246
Mailing Address - Fax:770-991-5012
Practice Address - Street 1:3154 ABBEY DR SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5467
Practice Address - Country:US
Practice Address - Phone:404-803-5246
Practice Address - Fax:770-991-5012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-09
Last Update Date:2016-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA037708207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00603006IMedicaid
GA00603006IMedicaid
GA11BDKDLMedicare PIN