Provider Demographics
NPI:1790966976
Name:FAMILY PRACTICE OF ATLANTA LLC
Entity Type:Organization
Organization Name:FAMILY PRACTICE OF ATLANTA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SONDI
Authorized Official - Middle Name:SADDIA
Authorized Official - Last Name:MOORE-WATERS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-296-8100
Mailing Address - Street 1:1428 SCOTT BLVD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-1424
Mailing Address - Country:US
Mailing Address - Phone:404-296-8100
Mailing Address - Fax:404-294-8467
Practice Address - Street 1:1428 SCOTT BLVD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1424
Practice Address - Country:US
Practice Address - Phone:404-296-8100
Practice Address - Fax:404-294-8467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-16
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031294261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6402OtherMEDICARE GROUP