Provider Demographics
NPI:1972537975
Name:MEDCARE PHYAICIANS CENTER, LLC
Entity Type:Organization
Organization Name:MEDCARE PHYAICIANS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-479-4291
Mailing Address - Street 1:1065 JODECO RD
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4953
Mailing Address - Country:US
Mailing Address - Phone:678-284-6300
Mailing Address - Fax:678-284-6336
Practice Address - Street 1:2004 MCDONOUGH RD
Practice Address - Street 2:SUITE 100
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-3259
Practice Address - Country:US
Practice Address - Phone:678-479-4291
Practice Address - Fax:678-479-4295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP5098Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER