Provider Demographics
NPI:1306013594
Name:FAMILY MEDICAL CLINIC OF LAWRENCEVILLE
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC OF LAWRENCEVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IRANDATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-225-5540
Mailing Address - Street 1:2522 CRUSE RD
Mailing Address - Street 2:C-2
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-2750
Mailing Address - Country:US
Mailing Address - Phone:678-225-5540
Mailing Address - Fax:678-225-5541
Practice Address - Street 1:2522 CRUSE RD
Practice Address - Street 2:C-2
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-2750
Practice Address - Country:US
Practice Address - Phone:678-225-5540
Practice Address - Fax:678-225-5541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty