Provider Demographics
NPI:1669502480
Name:EAST COBB MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:EAST COBB MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:K
Authorized Official - Last Name:IRUNGU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-924-2252
Mailing Address - Street 1:3750 PALLADIAN VILLAGE DR
Mailing Address - Street 2:STE 400
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-8200
Mailing Address - Country:US
Mailing Address - Phone:770-924-2252
Mailing Address - Fax:
Practice Address - Street 1:3750 PALLADIAN VILLAGE DR
Practice Address - Street 2:STE 400
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-8200
Practice Address - Country:US
Practice Address - Phone:770-924-2252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049588207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH49957Medicare UPIN