Provider Demographics
NPI:1093767923
Name:SYNERGY MEDICAL CENTERS, LLC.
Entity Type:Organization
Organization Name:SYNERGY MEDICAL CENTERS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:BUBOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-975-1299
Mailing Address - Street 1:3889 COBB PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-4084
Mailing Address - Country:US
Mailing Address - Phone:770-975-1299
Mailing Address - Fax:770-975-1361
Practice Address - Street 1:3889 COBB PKWY NW
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-4084
Practice Address - Country:US
Practice Address - Phone:770-975-1299
Practice Address - Fax:770-975-1361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA018938174400000X
GAPT006876174400000X
GA5860470001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5860470001OtherCIGNA GOVERNMENT SERVICES
GADC7392OtherRAILROAD PTAN
GAQ43335Medicare UPIN
GA5860470001Medicare NSC
GAI43817Medicare UPIN
GAGRP6873Medicare PIN