Provider Demographics
NPI:1609820745
Name:CHAMBLEE MEDICAL CLINIC
Entity Type:Organization
Organization Name:CHAMBLEE MEDICAL CLINIC
Other - Org Name:SOREN S THOMAS MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOREN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-458-0025
Mailing Address - Street 1:PO BOX 80042
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30366-0042
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3739 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-2062
Practice Address - Country:US
Practice Address - Phone:770-458-0025
Practice Address - Fax:770-458-0807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026895332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
1154284OtherOTHER ID NUMBER
1154284OtherOTHER ID NUMBER-COMMERCIAL NUMBER