Provider Demographics
NPI:1275047771
Name:ST LUKE MEDICAL CENTER INC
Entity Type:Organization
Organization Name:ST LUKE MEDICAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLSONA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-718-1517
Mailing Address - Street 1:1631 ATLANTA RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30504-5942
Mailing Address - Country:US
Mailing Address - Phone:770-718-1517
Mailing Address - Fax:770-718-1518
Practice Address - Street 1:1631 ATLANTA RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30504-5942
Practice Address - Country:US
Practice Address - Phone:770-718-1517
Practice Address - Fax:770-718-1518
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA45753OtherSTATE LICENSE
GA19606OtherSTATE LICENSE