Provider Demographics
NPI:1851423057
Name:OAKWOOD MEDICAL CLINIC
Entity Type:Organization
Organization Name:OAKWOOD MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BASIL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-503-9285
Mailing Address - Street 1:3626 OLD OAKWOOD RD
Mailing Address - Street 2:
Mailing Address - City:OAKWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30566
Mailing Address - Country:US
Mailing Address - Phone:770-503-9285
Mailing Address - Fax:770-287-0477
Practice Address - Street 1:3626 OLD OAKWOOD RD
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566
Practice Address - Country:US
Practice Address - Phone:770-503-9285
Practice Address - Fax:770-287-0477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0321020261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00469796DMedicaid
GA511G700320Medicare PIN
GAE18740Medicare UPIN