Provider Demographics
NPI:1962491381
Name:REDMOND PHYSICIAN PRACTICE COMPANY
Entity Type:Organization
Organization Name:REDMOND PHYSICIAN PRACTICE COMPANY
Other - Org Name:REDMOND FAMILY CARE CENTER AT CEDARTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7604
Mailing Address - Street 1:118 E GIRARD AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CEDARTOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30125-2778
Mailing Address - Country:US
Mailing Address - Phone:770-749-1005
Mailing Address - Fax:770-749-1119
Practice Address - Street 1:118 E GIRARD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:CEDARTOWN
Practice Address - State:GA
Practice Address - Zip Code:30125-2778
Practice Address - Country:US
Practice Address - Phone:770-749-1005
Practice Address - Fax:770-749-1119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-18
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CB6391Medicare PIN
GAGRP2870Medicare PIN