Provider Demographics
NPI:1659587947
Name:DULUTH FAMILY MEDICINE
Entity Type:Organization
Organization Name:DULUTH FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:770-495-0155
Mailing Address - Street 1:3855 PLEASANT HILL RD
Mailing Address - Street 2:STE 100
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096
Mailing Address - Country:US
Mailing Address - Phone:770-495-0155
Mailing Address - Fax:770-813-1298
Practice Address - Street 1:3855 PLEASANT HILL RD
Practice Address - Street 2:STE 100
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:770-495-0155
Practice Address - Fax:770-813-1298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7077OtherLEGACY