Provider Demographics
NPI:1013209733
Name:PHOENIX MEDICAL GROUP OF GA LLC
Entity Type:Organization
Organization Name:PHOENIX MEDICAL GROUP OF GA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MADEJ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:678-814-4901
Mailing Address - Street 1:P.O. BOX 740209
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30370-4029
Mailing Address - Country:US
Mailing Address - Phone:678-814-4901
Mailing Address - Fax:678-814-4908
Practice Address - Street 1:917 JONESBORO ROAD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6031
Practice Address - Country:US
Practice Address - Phone:678-814-4901
Practice Address - Fax:678-814-4908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty