Provider Demographics
NPI:1598000234
Name:MEDICAL WELLNESS GROUP
Entity Type:Organization
Organization Name:MEDICAL WELLNESS GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:IDRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-256-7033
Mailing Address - Street 1:1276 CEDAR KEYS CT
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-1811
Mailing Address - Country:US
Mailing Address - Phone:770-256-7033
Mailing Address - Fax:
Practice Address - Street 1:2015 MLK JR DRIVE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310
Practice Address - Country:US
Practice Address - Phone:770-256-7033
Practice Address - Fax:678-705-3717
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39485261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty