Provider Demographics
NPI:1104204379
Name:EXECUTIVE MEDICAL ASSOCIATES P.C.
Entity Type:Organization
Organization Name:EXECUTIVE MEDICAL ASSOCIATES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-572-7574
Mailing Address - Street 1:59 BEAMS WAY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-2517
Mailing Address - Country:US
Mailing Address - Phone:678-779-7038
Mailing Address - Fax:
Practice Address - Street 1:4426 HUGH HOWELL RD
Practice Address - Street 2:SUITE B303
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4918
Practice Address - Country:US
Practice Address - Phone:770-572-7574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN162951261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center