Provider Demographics
NPI:1922118595
Name:IVY FALLS FAMILY MEDICINE
Entity Type:Organization
Organization Name:IVY FALLS FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SELLS
Authorized Official - Suffix:
Authorized Official - Credentials:CMOM, CMIS,CMC
Authorized Official - Phone:678-990-4828
Mailing Address - Street 1:10475 MEDLOCK BRIDGE RD
Mailing Address - Street 2:SUITE 815
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-2002
Mailing Address - Country:US
Mailing Address - Phone:678-990-4828
Mailing Address - Fax:678-990-4824
Practice Address - Street 1:10475 MEDLOCK BRIDGE RD
Practice Address - Street 2:SUITE 815
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-2002
Practice Address - Country:US
Practice Address - Phone:678-990-4828
Practice Address - Fax:678-990-4824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GABL0600486261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7795Medicare PIN
GAF57767Medicare UPIN