Provider Demographics
NPI:1205032836
Name:MATERNAL AND FAMILY MEDICINE CTR
Entity Type:Organization
Organization Name:MATERNAL AND FAMILY MEDICINE CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAREMONT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-831-9956
Mailing Address - Street 1:1630 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1839
Mailing Address - Country:US
Mailing Address - Phone:770-831-9956
Mailing Address - Fax:770-831-9958
Practice Address - Street 1:1630 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:STE A
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1839
Practice Address - Country:US
Practice Address - Phone:770-831-9956
Practice Address - Fax:770-831-9958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA051967207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6874Medicare ID - Type Unspecified