Provider Demographics
NPI:1235446394
Name:INTOWN FAMILY PRACTICE & SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:INTOWN FAMILY PRACTICE & SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:LEO
Authorized Official - Last Name:GOLUSINSKI
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:404-577-7800
Mailing Address - Street 1:285 BOULEVARD AVE NE
Mailing Address - Street 2:SUITE 640
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30312-4212
Mailing Address - Country:US
Mailing Address - Phone:404-577-7800
Mailing Address - Fax:404-577-7810
Practice Address - Street 1:285 BOULEVARD AVE NE
Practice Address - Street 2:SUITE 640
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30312-4212
Practice Address - Country:US
Practice Address - Phone:404-577-7800
Practice Address - Fax:404-577-7810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-09
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038777261QP2300X
NC20330261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA160928OtherCOVENTRY HEALTHCARE
GA52476640002OtherBCBS OF GA
GA0191191OtherUNITED HEALTHCARE
GA4546534OtherAETNA
GA1013698006OtherCIGNA HEALTHCARE
GA776894OtherFIRST HEALTH
GA4546534OtherAETNA
GA776894OtherFIRST HEALTH
GA52476640002OtherBCBS OF GA
GA776894OtherFIRST HEALTH