Provider Demographics
NPI:1710922075
Name:CAEDEL MEDICAL GROUP
Entity Type:Organization
Organization Name:CAEDEL MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAIRE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-907-4949
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-0009
Mailing Address - Country:US
Mailing Address - Phone:770-907-4949
Mailing Address - Fax:770-907-4022
Practice Address - Street 1:1324 HIGHWAY 138 SW
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30296-1404
Practice Address - Country:US
Practice Address - Phone:770-907-4949
Practice Address - Fax:770-907-4022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6482Medicare PIN