Provider Demographics
NPI:1104399674
Name:FEDERAL INJURY CENTER OF ATLANTA
Entity Type:Organization
Organization Name:FEDERAL INJURY CENTER OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:STALLWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-997-0167
Mailing Address - Street 1:1600 MACY DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-6349
Mailing Address - Country:US
Mailing Address - Phone:678-878-3334
Mailing Address - Fax:678-878-3334
Practice Address - Street 1:1600 MACY DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-6349
Practice Address - Country:US
Practice Address - Phone:678-878-3334
Practice Address - Fax:678-878-3442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-08
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty