Provider Demographics
NPI:1578734893
Name:J. MICHAEL PETWAY, M.D., P.C.
Entity Type:Organization
Organization Name:J. MICHAEL PETWAY, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PETWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FCC P
Authorized Official - Phone:770-886-6718
Mailing Address - Street 1:562 LAKELAND PLZ
Mailing Address - Street 2:SUITE #158
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2783
Mailing Address - Country:US
Mailing Address - Phone:770-886-6718
Mailing Address - Fax:
Practice Address - Street 1:106 PILGRIM VILLAGE DR
Practice Address - Street 2:SUITE 400
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-9241
Practice Address - Country:US
Practice Address - Phone:770-886-6718
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA21271207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty