Provider Demographics
NPI:1255665170
Name:PICKFORD MEDICAL SERVICES, LLC.
Entity Type:Organization
Organization Name:PICKFORD MEDICAL SERVICES, LLC.
Other - Org Name:PICKFORD MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-622-9446
Mailing Address - Street 1:7325 AMBERLEIGH WAY
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-1873
Mailing Address - Country:US
Mailing Address - Phone:404-514-4139
Mailing Address - Fax:
Practice Address - Street 1:7810 MCGINNIS FERRY RD
Practice Address - Street 2:SUITE #108
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-1633
Practice Address - Country:US
Practice Address - Phone:770-622-9446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG15114Medicare UPIN