Provider Demographics
NPI:1558887018
Name:MIGUEL E. STUBBS, MD PC
Entity Type:Organization
Organization Name:MIGUEL E. STUBBS, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:STUBBS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-803-5246
Mailing Address - Street 1:6724 CHURCH ST STE 3
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4711
Mailing Address - Country:US
Mailing Address - Phone:770-991-6186
Mailing Address - Fax:770-991-5012
Practice Address - Street 1:4760 AUSTELL RD STE 1
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-2007
Practice Address - Country:US
Practice Address - Phone:404-803-5146
Practice Address - Fax:770-991-5012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0060300IMedicaid
GAN688290OtherINTERNAL MEDICINE