Provider Demographics
NPI:1326340829
Name:SMOKERISE FAMILY MEDICAL ASSOC
Entity Type:Organization
Organization Name:SMOKERISE FAMILY MEDICAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PHYSICIAN/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LESLEY
Authorized Official - Last Name:BARON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-469-1711
Mailing Address - Street 1:1505 LILBURN STONE MOUNTAIN RD
Mailing Address - Street 2:STE 100
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-1857
Mailing Address - Country:US
Mailing Address - Phone:770-469-1711
Mailing Address - Fax:770-469-1837
Practice Address - Street 1:1505 LILBURN STONE MOUNTAIN RD
Practice Address - Street 2:STE 100
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-1857
Practice Address - Country:US
Practice Address - Phone:770-469-1711
Practice Address - Fax:770-469-1837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0033273207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00474779AMedicaid
E86249Medicare UPIN
08LCBDRMedicare PIN