Provider Demographics
NPI:1811400724
Name:MID PHYSICIAN NETWORK (IN), LLC
Entity Type:Organization
Organization Name:MID PHYSICIAN NETWORK (IN), LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:855-879-4332
Mailing Address - Street 1:PO BOX 6760
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31758-6760
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5665 NEW NORTHSIDE DR
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5831
Practice Address - Country:US
Practice Address - Phone:855-879-4332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MYIDEALDOCTOR LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health