Provider Demographics
NPI:1396033064
Name:PHOENIX MEDICAL OFFICE AT COLLEGE PARK,LLC
Entity Type:Organization
Organization Name:PHOENIX MEDICAL OFFICE AT COLLEGE PARK,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:MAURICE
Authorized Official - Last Name:HAMNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-788-8950
Mailing Address - Street 1:1631 PHOENIX BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-5545
Mailing Address - Country:US
Mailing Address - Phone:678-788-8950
Mailing Address - Fax:678-788-8953
Practice Address - Street 1:1631 PHOENIX BLVD STE 4
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-5545
Practice Address - Country:US
Practice Address - Phone:678-788-8950
Practice Address - Fax:678-788-8953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-15
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39813207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty