Provider Demographics
NPI:1497951081
Name:AMARC MEDICAL & RESEARCH CLINIC
Entity Type:Organization
Organization Name:AMARC MEDICAL & RESEARCH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BONA
Authorized Official - Middle Name:
Authorized Official - Last Name:ILONZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-838-0904
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-0767
Mailing Address - Country:US
Mailing Address - Phone:404-838-0904
Mailing Address - Fax:770-446-2686
Practice Address - Street 1:1309 LAKEWOOD AVE SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-2312
Practice Address - Country:US
Practice Address - Phone:404-838-0904
Practice Address - Fax:770-446-2686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7375Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER