Provider Demographics
NPI:1710286414
Name:NORTHLAKE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:NORTHLAKE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BUDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:770-496-2929
Mailing Address - Street 1:2175 NORTHLAKE PKWY
Mailing Address - Street 2:ST 142,BLDG 4
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-4163
Mailing Address - Country:US
Mailing Address - Phone:770-496-2929
Mailing Address - Fax:770-496-2930
Practice Address - Street 1:2175 NORTHLAKE PKWY
Practice Address - Street 2:ST 142,BLDG 4
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4163
Practice Address - Country:US
Practice Address - Phone:770-496-2929
Practice Address - Fax:770-496-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017369261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty