Provider Demographics
NPI:1225709843
Name:GEORGIA CLINIC PATIENT OUTREACH LLC
Entity Type:Organization
Organization Name:GEORGIA CLINIC PATIENT OUTREACH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:NINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-820-1017
Mailing Address - Street 1:6330 PRIMROSE HILL CT # 108
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-4544
Mailing Address - Country:US
Mailing Address - Phone:770-903-0144
Mailing Address - Fax:
Practice Address - Street 1:6330 PRIMROSE HILL CT # 108
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4544
Practice Address - Country:US
Practice Address - Phone:770-903-0144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty