Provider Demographics
NPI:1487849857
Name:MED FAST PC
Entity Type:Organization
Organization Name:MED FAST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MIKRUT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-554-5533
Mailing Address - Street 1:902 ATHENS HWY
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-4904
Mailing Address - Country:US
Mailing Address - Phone:770-554-5533
Mailing Address - Fax:770-554-8129
Practice Address - Street 1:902 ATHENS HWY
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-4904
Practice Address - Country:US
Practice Address - Phone:770-554-5533
Practice Address - Fax:770-554-8129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA29730261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6328OtherMEDICARE GROUP