Provider Demographics
NPI:1326381690
Name:INSTITUTE FOR PERSONALIZED MEDICINE
Entity Type:Organization
Organization Name:INSTITUTE FOR PERSONALIZED MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-352-1234
Mailing Address - Street 1:3 JOHNSTON ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-5502
Mailing Address - Country:US
Mailing Address - Phone:912-352-1234
Mailing Address - Fax:
Practice Address - Street 1:3 JOHNSTON ST
Practice Address - Street 2:SUITE B
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5502
Practice Address - Country:US
Practice Address - Phone:912-352-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55437174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty