Provider Demographics
NPI:1669658829
Name:ADVANCED INTERNAL MEDICINE
Entity Type:Organization
Organization Name:ADVANCED INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FAOSAT
Authorized Official - Middle Name:O
Authorized Official - Last Name:ODEMUYIWA
Authorized Official - Suffix:
Authorized Official - Credentials:MSC
Authorized Official - Phone:770-960-8855
Mailing Address - Street 1:PO BOX 870116
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30287-0116
Mailing Address - Country:US
Mailing Address - Phone:770-960-8855
Mailing Address - Fax:678-565-1140
Practice Address - Street 1:235 MEDICAL BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7218
Practice Address - Country:US
Practice Address - Phone:770-960-8855
Practice Address - Fax:678-565-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-17
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA07-12143261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care