Provider Demographics
NPI:1255690475
Name:MEDIC ONE LLC
Entity Type:Organization
Organization Name:MEDIC ONE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:ADESUPO
Authorized Official - Middle Name:
Authorized Official - Last Name:OSHIYOYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-894-3167
Mailing Address - Street 1:PO BOX 670508
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-0126
Mailing Address - Country:US
Mailing Address - Phone:770-894-3167
Mailing Address - Fax:770-575-0879
Practice Address - Street 1:2621 SANDY PLAINS RD
Practice Address - Street 2:SUITE 304
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-4267
Practice Address - Country:US
Practice Address - Phone:770-894-3167
Practice Address - Fax:770-575-0879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-08
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA51736207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty