Provider Demographics
NPI:1386662849
Name:PROFESSIONAL PARK MEDICAL SERVICES, P.C.
Entity Type:Organization
Organization Name:PROFESSIONAL PARK MEDICAL SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTICE MD
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:TAYLOR
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-832-6861
Mailing Address - Street 1:SUITE 202
Mailing Address - Street 2:100 PROFESSIONAL PARK
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117
Mailing Address - Country:US
Mailing Address - Phone:770-832-6861
Mailing Address - Fax:770-832-9432
Practice Address - Street 1:SUITE 202
Practice Address - Street 2:100 PROFESSIONAL PARK
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117
Practice Address - Country:US
Practice Address - Phone:770-832-6861
Practice Address - Fax:770-832-9432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACJ2154OtherMEDICARE RAILROAD
GRP1919Medicare ID - Type Unspecified