Provider Demographics
NPI:1922680354
Name:DRMICHAELWANGPT, LLC
Entity Type:Organization
Organization Name:DRMICHAELWANGPT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:678-388-9504
Mailing Address - Street 1:4870 PEACHTREE INDUSTRIAL BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:BERKELEY LAKE
Mailing Address - State:GA
Mailing Address - Zip Code:30071-5734
Mailing Address - Country:US
Mailing Address - Phone:678-388-9504
Mailing Address - Fax:404-777-3474
Practice Address - Street 1:4870 PEACHTREE INDUSTRIAL BLVD STE 600
Practice Address - Street 2:
Practice Address - City:BERKELEY LAKE
Practice Address - State:GA
Practice Address - Zip Code:30071-5734
Practice Address - Country:US
Practice Address - Phone:678-388-9504
Practice Address - Fax:404-777-3474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003190230BMedicaid