Provider Demographics
NPI:1265029045
Name:FOUNDATION MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:FOUNDATION MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NAOMI
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTANEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-506-0526
Mailing Address - Street 1:160 CLAIREMONT AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2546
Mailing Address - Country:US
Mailing Address - Phone:804-506-0526
Mailing Address - Fax:
Practice Address - Street 1:160 CLAIREMONT AVE STE 200
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2546
Practice Address - Country:US
Practice Address - Phone:706-534-8574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-28
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty