Provider Demographics
NPI:1922130012
Name:CLASSICARE MEDICAL CONSULT PC, INC
Entity Type:Organization
Organization Name:CLASSICARE MEDICAL CONSULT PC, INC
Other - Org Name:CLASSICARE INTERNAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:XIANGDONG
Authorized Official - Middle Name:
Authorized Official - Last Name:YOU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-489-5000
Mailing Address - Street 1:4904 TIMBER RIDGE DR STE 303
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1831
Mailing Address - Country:US
Mailing Address - Phone:770-489-5000
Mailing Address - Fax:770-489-0305
Practice Address - Street 1:4904 TIMBER RIDGE DR STE 303
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1831
Practice Address - Country:US
Practice Address - Phone:770-489-5000
Practice Address - Fax:770-489-0305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050465207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2089568OtherFIRST HEALTHCARE
GA320129OtherWELLCARE OF GEORGIA
GA000934007EMedicaid
52895315OtherBCBS
6104OtherKAISER
7676325OtherAETNA
3462913OtherCIGNA
P00242355OtherMEDICARE RAILROAD
0403355OtherUNITED HEALTH CARE
782253003OtherGREAT-WEST
21232609899OtherBEECH STREET
258835797OtherTRICARE
=========OtherCOVENTRY
52895315OtherBCBS
258835797OtherTRICARE
P00242355OtherMEDICARE RAILROAD
=========OtherSOUTHCARE
P00242355OtherMEDICARE RAILROAD