Provider Demographics
NPI:1013096882
Name:SEGEN MEDICAL GROUP, P.C.
Entity Type:Organization
Organization Name:SEGEN MEDICAL GROUP, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:GHEBREMESKEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-939-3301
Mailing Address - Street 1:PO BOX 671077
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-0135
Mailing Address - Country:US
Mailing Address - Phone:770-939-3301
Mailing Address - Fax:770-939-3331
Practice Address - Street 1:3950 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1121
Practice Address - Country:US
Practice Address - Phone:770-939-3301
Practice Address - Fax:770-939-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA45801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000799719DMedicaid
GAH00731Medicare UPIN
GA000799719DMedicaid