Provider Demographics
NPI:1568628618
Name:FAMILY MEDICAL CLINIC OF SNELLVILLE
Entity Type:Organization
Organization Name:FAMILY MEDICAL CLINIC OF SNELLVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-972-4764
Mailing Address - Street 1:3891 STONE MOUNTAIN HWY
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-3932
Mailing Address - Country:US
Mailing Address - Phone:770-972-4764
Mailing Address - Fax:770-972-4164
Practice Address - Street 1:3891 STONE MOUNTAIN HWY
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30039-3932
Practice Address - Country:US
Practice Address - Phone:770-972-4764
Practice Address - Fax:770-972-4164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA023958261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52260821001OtherBC PROVIDER ID
1083652267OtherIND. NPI
GA4073314OtherAETNA PROVIDER ID
GA511G700755Medicare PIN