Provider Demographics
NPI: | 1659401487 |
---|---|
Name: | MOREHOUSE MEDICAL ASSOCIATE |
Entity Type: | Organization |
Organization Name: | MOREHOUSE MEDICAL ASSOCIATE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CREDENTIALING MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JASMINE |
Authorized Official - Middle Name: | S |
Authorized Official - Last Name: | BAJNATH |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 404-756-5752 |
Mailing Address - Street 1: | 720 WESTVIEW DR SW STE 100 |
Mailing Address - Street 2: | |
Mailing Address - City: | ATLANTA |
Mailing Address - State: | GA |
Mailing Address - Zip Code: | 30310-1458 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 404-756-5752 |
Mailing Address - Fax: | 404-756-5274 |
Practice Address - Street 1: | 1513 CLEVELAND AVE |
Practice Address - Street 2: | 500 |
Practice Address - City: | EAST POINT |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30344-6947 |
Practice Address - Country: | US |
Practice Address - Phone: | 404-752-1000 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-03-07 |
Last Update Date: | 2018-03-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
GA | 51 | 261QP2300X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QP2300X | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |