Provider Demographics
NPI:1982190039
Name:PEACHTREE IMMEDIATE CARE FP, LLC
Entity Type:Organization
Organization Name:PEACHTREE IMMEDIATE CARE FP, LLC
Other - Org Name:PEACHTREE IMMEDIATE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALIK-ROE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-504-6392
Mailing Address - Street 1:1275 HIGHWAY 54 W STE 201
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-4538
Mailing Address - Country:US
Mailing Address - Phone:678-688-9685
Mailing Address - Fax:770-626-3791
Practice Address - Street 1:3885 MUNDY MILL RD STE 114
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566-3432
Practice Address - Country:US
Practice Address - Phone:678-971-1892
Practice Address - Fax:678-971-1895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAINV-3-18-12009207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty