Provider Demographics
NPI:1578828893
Name:ATLANTA MEDICAL ARTS AND WELLNESS, LLC
Entity Type:Organization
Organization Name:ATLANTA MEDICAL ARTS AND WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICE
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-801-0980
Mailing Address - Street 1:5055 BRER RABBIT RD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-1858
Mailing Address - Country:US
Mailing Address - Phone:770-801-0980
Mailing Address - Fax:770-801-9039
Practice Address - Street 1:1800 WATER PL SE STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2041
Practice Address - Country:US
Practice Address - Phone:770-801-0980
Practice Address - Fax:770-801-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA048274207R00000X, 2083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG23404Medicare UPIN