Provider Demographics
NPI:1457494502
Name:DUNWOODY VILLAGE CLINIC, PC
Entity Type:Organization
Organization Name:DUNWOODY VILLAGE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DUNWOODY VILLAGE CLINIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:KINAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD PHD
Authorized Official - Phone:770-481-0889
Mailing Address - Street 1:5471 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-4114
Mailing Address - Country:US
Mailing Address - Phone:770-481-0889
Mailing Address - Fax:770-481-0986
Practice Address - Street 1:5471 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338
Practice Address - Country:US
Practice Address - Phone:770-481-0889
Practice Address - Fax:770-481-0986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F97728Medicare UPIN
11BDJDTMedicare ID - Type Unspecified
11SCDSFMedicare ID - Type Unspecified