Provider Demographics
NPI:1205113065
Name:PEACHTREE PHYSICAL MEDICINE GROUP
Entity type:Organization
Organization Name:PEACHTREE PHYSICAL MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-454-8300
Mailing Address - Street 1:1140 HAMMOND DR NE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5338
Mailing Address - Country:US
Mailing Address - Phone:770-454-8300
Mailing Address - Fax:770-986-9962
Practice Address - Street 1:1140 HAMMOND DR NE
Practice Address - Street 2:SUITE 110
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5338
Practice Address - Country:US
Practice Address - Phone:770-454-8300
Practice Address - Fax:770-986-9962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation