Provider Demographics
NPI:1326472283
Name:NORTH FULTON PRIMARY CARE - WYLIE BRIDGE, LLC
Entity Type:Organization
Organization Name:NORTH FULTON PRIMARY CARE - WYLIE BRIDGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL CFO, TENET
Authorized Official - Prefix:MR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-265-5009
Mailing Address - Street 1:PO BOX 742595
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2595
Mailing Address - Country:US
Mailing Address - Phone:678-293-7854
Mailing Address - Fax:770-740-8503
Practice Address - Street 1:14205 HIGHWAY 92
Practice Address - Street 2:SUITE 105
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-7138
Practice Address - Country:US
Practice Address - Phone:678-293-7854
Practice Address - Fax:770-740-8503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Multi-Specialty