Provider Demographics
NPI:1255518478
Name:PEACHSTREET IMMEDIATE CARE CENTER
Entity type:Organization
Organization Name:PEACHSTREET IMMEDIATE CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIEM
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-398-5440
Mailing Address - Street 1:4426 AUSTELL RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1844
Mailing Address - Country:US
Mailing Address - Phone:678-398-5440
Mailing Address - Fax:678-398-5442
Practice Address - Street 1:4426 AUSTELL RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1844
Practice Address - Country:US
Practice Address - Phone:678-398-5440
Practice Address - Fax:678-398-5442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6724Medicare PIN