Provider Demographics
NPI:1124596069
Name:LONGEVITY MEDICAL CENTER, PC
Entity Type:Organization
Organization Name:LONGEVITY MEDICAL CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOO
Authorized Official - Prefix:
Authorized Official - First Name:SAIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULTAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-676-6000
Mailing Address - Street 1:1551 DUNWOODY VILLAGE PKWY UNIT 888426
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30356-0115
Mailing Address - Country:US
Mailing Address - Phone:678-736-6383
Mailing Address - Fax:678-280-6761
Practice Address - Street 1:4646 N SHALLOWFORD RD STE 300
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30338-6308
Practice Address - Country:US
Practice Address - Phone:678-736-6383
Practice Address - Fax:678-280-6761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty