Provider Demographics
NPI:1538458690
Name:METAMORPHOSIS MEDICAL GROUP
Entity Type:Organization
Organization Name:METAMORPHOSIS MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:LEVICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-218-1710
Mailing Address - Street 1:1792 WOODSTOCK RD
Mailing Address - Street 2:BLDG 300
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-2199
Mailing Address - Country:US
Mailing Address - Phone:678-218-1710
Mailing Address - Fax:678-218-1714
Practice Address - Street 1:1792 WOODSTOCK RD
Practice Address - Street 2:BLDG 300
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-2199
Practice Address - Country:US
Practice Address - Phone:678-218-1710
Practice Address - Fax:678-218-1714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044520261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty