Provider Demographics
NPI:1346595204
Name:COVENANT FAMILY MEDICINE GMG LLC
Entity Type:Organization
Organization Name:COVENANT FAMILY MEDICINE GMG LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-325-0150
Mailing Address - Street 1:2069 TERON TRCE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1665
Mailing Address - Country:US
Mailing Address - Phone:678-730-1620
Mailing Address - Fax:
Practice Address - Street 1:2098 TERON TRCE
Practice Address - Street 2:SUITE 150
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1663
Practice Address - Country:US
Practice Address - Phone:678-730-1620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GWINNETT MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-17
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty