Provider Demographics
NPI:1154319952
Name:PETWAY, JAMES MICHAEL (MD, FCCP)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:MICHAEL
Last Name:PETWAY
Suffix:
Gender:M
Credentials:MD, FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 DAHLONEGA ST
Mailing Address - Street 2:STE 804
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-8209
Mailing Address - Country:US
Mailing Address - Phone:770-886-6718
Mailing Address - Fax:770-886-6624
Practice Address - Street 1:327 DAHLONEGA ST
Practice Address - Street 2:SUITE 804
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-8209
Practice Address - Country:US
Practice Address - Phone:770-886-6718
Practice Address - Fax:770-886-6624
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA021271174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000276438PMedicaid
GAF44203Medicare UPIN
GA000276438PMedicaid