Provider Demographics
NPI:1467572321
Name:BETHEL GROUP OF GEORGIA INC
Entity Type:Organization
Organization Name:BETHEL GROUP OF GEORGIA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:JUAN
Authorized Official - Last Name:BACALLAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-735-9844
Mailing Address - Street 1:2870 PEACHTREE RD NW
Mailing Address - Street 2:SUITE 919
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-2918
Mailing Address - Country:US
Mailing Address - Phone:404-735-9844
Mailing Address - Fax:404-355-4669
Practice Address - Street 1:2870 PEACHTREE RD NW
Practice Address - Street 2:SUITE 919
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305-2918
Practice Address - Country:US
Practice Address - Phone:404-735-9844
Practice Address - Fax:404-355-4669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA139625LGB208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty