Provider Demographics
NPI:1639567472
Name:ATLANTA INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:ATLANTA INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JO
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-858-5252
Mailing Address - Street 1:2400 PLEASANT HILL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4396
Mailing Address - Country:US
Mailing Address - Phone:770-858-5252
Mailing Address - Fax:
Practice Address - Street 1:2400 PLEASANT HILL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4396
Practice Address - Country:US
Practice Address - Phone:770-858-5252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-02
Last Update Date:2015-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA64660261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003109338AMedicaid
GA003109338AMedicaid