Provider Demographics
NPI:1568594299
Name:MOUNT VERNON INTERNAL MEDICINE, LLP
Entity Type:Organization
Organization Name:MOUNT VERNON INTERNAL MEDICINE, LLP
Other - Org Name:MOUNT MOUNT VERNON INTERNAL MEDICINE, LLP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:STEGGS
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CMPE
Authorized Official - Phone:404-419-9960
Mailing Address - Street 1:755 MOUNT VERNON HIGHWAY, N.E.
Mailing Address - Street 2:SUITE 400
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4279
Mailing Address - Country:US
Mailing Address - Phone:404-252-4100
Mailing Address - Fax:404-252-6740
Practice Address - Street 1:755 MOUNT VERNON HIGHWAY, N.E.
Practice Address - Street 2:SUITE 400
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4279
Practice Address - Country:US
Practice Address - Phone:404-252-4100
Practice Address - Fax:404-252-6740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051442174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051442OtherSTATE LICENSE NUMBER
GA051442OtherGA STATE LICENSE NUMBER
GA051442OtherGA STATE LICENSE NUMBER
GA051442OtherSTATE LICENSE NUMBER
GA11BDVRGMedicare PIN