Provider Demographics
NPI:1942240346
Name:PHYSICIANS' IMMEDIATE MED
Entity Type:Organization
Organization Name:PHYSICIANS' IMMEDIATE MED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BRANCH MANAGER/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:P
Authorized Official - Last Name:HART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-505-3000
Mailing Address - Street 1:10905 HAYNES BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-4807
Mailing Address - Country:US
Mailing Address - Phone:770-505-3000
Mailing Address - Fax:770-753-4228
Practice Address - Street 1:10905 HAYNES BRIDGE RD
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-4807
Practice Address - Country:US
Practice Address - Phone:770-505-3000
Practice Address - Fax:770-753-4228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP4233Medicare ID - Type Unspecified