Provider Demographics
NPI:1871669358
Name:GRANT PARK FAMILY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:GRANT PARK FAMILY HEALTH CENTER, INC.
Other - Org Name:GRANT PARK CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-627-4259
Mailing Address - Street 1:1340 BOULEVARD SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-3016
Mailing Address - Country:US
Mailing Address - Phone:404-627-4259
Mailing Address - Fax:404-624-5795
Practice Address - Street 1:1340 BOULEVARD SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-3016
Practice Address - Country:US
Practice Address - Phone:404-627-4259
Practice Address - Fax:404-624-5795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP585Medicare ID - Type UnspecifiedGEORGIA MEDICARE GROUP #