Provider Demographics
NPI:1275650921
Name:PEACHTREE MEDICAL CENTER
Entity Type:Organization
Organization Name:PEACHTREE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSCIAN
Authorized Official - Prefix:
Authorized Official - First Name:UNNISA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIYAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:770-487-7807
Mailing Address - Street 1:2579 HWY 54
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269
Mailing Address - Country:US
Mailing Address - Phone:770-487-7807
Mailing Address - Fax:
Practice Address - Street 1:2579 HWY 54
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269
Practice Address - Country:US
Practice Address - Phone:770-487-7807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022087261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA330666962 BMedicare PIN
GAE 54856Medicare UPIN