Provider Demographics
NPI:1972629814
Name:DEKALB FAMILY MEDICINE
Entity Type:Organization
Organization Name:DEKALB FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-220-0741
Mailing Address - Street 1:PO BOX 48833
Mailing Address - Street 2:
Mailing Address - City:DORAVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30362-1833
Mailing Address - Country:US
Mailing Address - Phone:770-220-0741
Mailing Address - Fax:770-220-2839
Practice Address - Street 1:4961 BUFORD HWY
Practice Address - Street 2:
Practice Address - City:CHAMBLEE
Practice Address - State:GA
Practice Address - Zip Code:30341-3503
Practice Address - Country:US
Practice Address - Phone:770-220-0741
Practice Address - Fax:770-220-2839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8010261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA8010OtherBUSINESS LICENSE