Provider Demographics
NPI:1477863579
Name:ST. JUDE'S INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:ST. JUDE'S INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:OSBORNE
Authorized Official - Middle Name:F
Authorized Official - Last Name:D'SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-324-7406
Mailing Address - Street 1:1198 BUCKHEAD XING
Mailing Address - Street 2:STE C
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-4257
Mailing Address - Country:US
Mailing Address - Phone:678-324-7406
Mailing Address - Fax:770-627-4322
Practice Address - Street 1:1198 BUCKHEAD XING
Practice Address - Street 2:STE C
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-4257
Practice Address - Country:US
Practice Address - Phone:678-324-7406
Practice Address - Fax:770-627-4322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-07
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty