Provider Demographics
NPI:1467072231
Name:FT MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:FT MEDICAL GROUP, LLC
Other - Org Name:ID-TECH MOLECULAR LABORATORIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DARRYLE
Authorized Official - Middle Name:MAURICE
Authorized Official - Last Name:FARRAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-245-5543
Mailing Address - Street 1:777 CLEVELAND AVE SW STE 516
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-7115
Mailing Address - Country:US
Mailing Address - Phone:404-245-5543
Mailing Address - Fax:
Practice Address - Street 1:777 CLEVELAND AVE SW STE 516
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7115
Practice Address - Country:US
Practice Address - Phone:404-915-8877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-22
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
0Other0