Provider Demographics
NPI:1255354122
Name:CAMP CREEK WOMEN'S HEALTH SPECIALIST
Entity type:Organization
Organization Name:CAMP CREEK WOMEN'S HEALTH SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/ CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:JERMAINE
Authorized Official - Last Name:EDMONDS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-344-2229
Mailing Address - Street 1:3890 REDWINE RD SW STE 106
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5509
Mailing Address - Country:US
Mailing Address - Phone:404-344-2229
Mailing Address - Fax:404-574-6715
Practice Address - Street 1:3890 REDWINE RD SW STE 106
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5509
Practice Address - Country:US
Practice Address - Phone:404-344-2229
Practice Address - Fax:404-574-6715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA55205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI50536Medicare UPIN
GAGRP7623Medicare ID - Type Unspecified