Provider Demographics
NPI:1548591399
Name:JAD MEDICAL GROUP
Entity Type:Organization
Organization Name:JAD MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ FAMILY PRACTICE PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-704-7519
Mailing Address - Street 1:510 SWANSON RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-6900
Mailing Address - Country:US
Mailing Address - Phone:770-964-5230
Mailing Address - Fax:770-964-5260
Practice Address - Street 1:510 SWANSON RD
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-6900
Practice Address - Country:US
Practice Address - Phone:770-964-5230
Practice Address - Fax:770-964-5260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032720207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD45611Medicare UPIN