Provider Demographics
NPI:1649739020
Name:ACCUMEDIC DIAGNOSTIC MANAGEMENT LLC
Entity Type:Organization
Organization Name:ACCUMEDIC DIAGNOSTIC MANAGEMENT LLC
Other - Org Name:ACCUMEDIC DIAGNOSTIC MANAGEMENT LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EMMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-487-7464
Mailing Address - Street 1:4760 AUSTELL RD STE 7
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-2007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:373 W LAKE AVE NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-8123
Practice Address - Country:US
Practice Address - Phone:770-366-9614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-15
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003142287SMedicaid
GA69322OtherLICENSE