Provider Demographics
NPI:1619242039
Name:RST MEDICAL GROUP
Entity Type:Organization
Organization Name:RST MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:CCMA
Authorized Official - Phone:404-422-0027
Mailing Address - Street 1:4150 SNAPFINGER WOODS DR
Mailing Address - Street 2:208
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-3417
Mailing Address - Country:US
Mailing Address - Phone:404-826-2877
Mailing Address - Fax:404-941-8788
Practice Address - Street 1:4150 SNAPFINGER WOODS DR
Practice Address - Street 2:208
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-3417
Practice Address - Country:US
Practice Address - Phone:404-826-2827
Practice Address - Fax:404-941-8788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-19
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN200088261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00804339DMedicaid