Provider Demographics
NPI:1598197758
Name:ROCDALE PHYSICIAN PRACTICES, LLC
Entity Type:Organization
Organization Name:ROCDALE PHYSICIAN PRACTICES, LLC
Other - Org Name:PREMIER HEALTHCARE ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-8505
Mailing Address - Street 1:PO BOX 116202
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6202
Mailing Address - Country:US
Mailing Address - Phone:770-922-0734
Mailing Address - Fax:770-922-0734
Practice Address - Street 1:5154 COOK ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2630
Practice Address - Country:US
Practice Address - Phone:770-788-1778
Practice Address - Fax:770-788-1285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-30
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA070244207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty