Provider Demographics
NPI:1518289248
Name:CREEKSIDE MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:CREEKSIDE MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHARMILA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMPRASAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-627-3986
Mailing Address - Street 1:3104 CREEKSIDE VILLAGE DR NW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2324
Mailing Address - Country:US
Mailing Address - Phone:770-627-3986
Mailing Address - Fax:770-872-0517
Practice Address - Street 1:3104 CREEKSIDE VILLAGE DR NW
Practice Address - Street 2:SUITE 201
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2324
Practice Address - Country:US
Practice Address - Phone:770-627-3986
Practice Address - Fax:770-872-0517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-22
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA839516023AMedicaid