Provider Demographics
NPI:1639574890
Name:GRUPO MEDICO DE GEORGIA, LLC
Entity Type:Organization
Organization Name:GRUPO MEDICO DE GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDDY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAJARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-831-9202
Mailing Address - Street 1:4225 S LEE ST STE B
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-3658
Mailing Address - Country:US
Mailing Address - Phone:770-831-9202
Mailing Address - Fax:
Practice Address - Street 1:5955 JIMMY CARTER BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-4641
Practice Address - Country:US
Practice Address - Phone:770-559-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008572111N00000X
GA38981207Q00000X
GARN105078363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty