Provider Demographics
NPI:1326218140
Name:RESTORA MEDICAL CENTER
Entity Type:Organization
Organization Name:RESTORA MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURKICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-368-8787
Mailing Address - Street 1:3459 HOLCOMB BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-3102
Mailing Address - Country:US
Mailing Address - Phone:770-368-8787
Mailing Address - Fax:
Practice Address - Street 1:3459 HOLCOMB BRIDGE RD
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-3102
Practice Address - Country:US
Practice Address - Phone:770-368-8787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA46372305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7800Medicare PIN