Provider Demographics
NPI:1801034574
Name:IDEAL MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:IDEAL MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-634-4550
Mailing Address - Street 1:3523 BUFORD HWY
Mailing Address - Street 2:STE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329
Mailing Address - Country:US
Mailing Address - Phone:404-634-4550
Mailing Address - Fax:404-634-8550
Practice Address - Street 1:3523 BUFORD HWY
Practice Address - Street 2:STE - 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-1279
Practice Address - Country:US
Practice Address - Phone:404-634-4550
Practice Address - Fax:404-634-8550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022068207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty