Provider Demographics
NPI:1184827917
Name:NORTHLAKE FAMILY MEDICINE
Entity Type:Organization
Organization Name:NORTHLAKE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:INDER
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:SINGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-493-1800
Mailing Address - Street 1:2130 LAVISTA EXEC PARK DR
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5421
Mailing Address - Country:US
Mailing Address - Phone:770-493-1800
Mailing Address - Fax:
Practice Address - Street 1:2130 LAVISTA EXEC PARK DR
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5421
Practice Address - Country:US
Practice Address - Phone:770-493-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040551207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000676574BMedicaid
GA000835095AMedicaid
GA000835095AMedicaid
GAG08349Medicare UPIN
GA000676574BMedicaid
GA08BDPDGMedicare ID - Type Unspecified