Provider Demographics
NPI:1629169164
Name:LOCUST GROVE FAMILY MEDICINE
Entity Type:Organization
Organization Name:LOCUST GROVE FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NIMISHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:TRIVEDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-610-6649
Mailing Address - Street 1:3778 HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-3632
Mailing Address - Country:US
Mailing Address - Phone:678-610-6649
Mailing Address - Fax:678-610-6025
Practice Address - Street 1:3778 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-3632
Practice Address - Country:US
Practice Address - Phone:678-610-6649
Practice Address - Fax:678-610-6025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053715207Q00000X, 332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherEIN