Provider Demographics
NPI:1780006064
Name:THE MEDI GROUP, LLC
Entity Type:Organization
Organization Name:THE MEDI GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:7706-338-5550
Mailing Address - Street 1:1257 COMMERCIAL DR SW STE B
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5991
Mailing Address - Country:US
Mailing Address - Phone:770-483-6393
Mailing Address - Fax:
Practice Address - Street 1:1257 COMMERCIAL DR SW STE B
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5991
Practice Address - Country:US
Practice Address - Phone:770-483-6393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251F00000XAgenciesHome Infusion
No251G00000XAgenciesHospice Care, Community Based
No251J00000XAgenciesNursing Care
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA543734780Medicaid