Provider Demographics
NPI:1801405998
Name:INTEGRATED MEDICAL OF GEORGIA, LLC
Entity Type:Organization
Organization Name:INTEGRATED MEDICAL OF GEORGIA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ENRIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRESPO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-428-4909
Mailing Address - Street 1:596 SEMINOLE DR NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1508
Mailing Address - Country:US
Mailing Address - Phone:770-428-4909
Mailing Address - Fax:
Practice Address - Street 1:596 SEMINOLE DR NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1508
Practice Address - Country:US
Practice Address - Phone:770-428-4909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty