Provider Demographics
NPI:1942686548
Name:BETHESDA MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:BETHESDA MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:770-241-1326
Mailing Address - Street 1:PO BOX 5
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-0005
Mailing Address - Country:US
Mailing Address - Phone:770-328-6398
Mailing Address - Fax:404-443-0690
Practice Address - Street 1:4039 ATLANTA ST STE 100
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-2666
Practice Address - Country:US
Practice Address - Phone:770-328-6398
Practice Address - Fax:706-793-9397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-05
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30053207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty