Provider Demographics
NPI:1255465217
Name:NORTHCREST FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:NORTHCREST FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD / OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-655-1408
Mailing Address - Street 1:7768 CUMMING HWY. STE 300
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:770-720-2113
Mailing Address - Fax:770-704-7365
Practice Address - Street 1:7768 CUMMING HWY
Practice Address - Street 2:SUITE 300
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-9314
Practice Address - Country:US
Practice Address - Phone:770-720-2113
Practice Address - Fax:770-704-7365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056102207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA978224987AMedicaid
GAGRP7458Medicare ID - Type Unspecified