Provider Demographics
NPI:1265136923
Name:EXECUTIVE MEDICAL PRACTICE L.L.C.
Entity type:Organization
Organization Name:EXECUTIVE MEDICAL PRACTICE L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDITIALING
Authorized Official - Prefix:
Authorized Official - First Name:RASHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-664-2997
Mailing Address - Street 1:1455 BELLS FERRY RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-6078
Mailing Address - Country:US
Mailing Address - Phone:770-421-8094
Mailing Address - Fax:770-421-8096
Practice Address - Street 1:1455 BELLS FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-6078
Practice Address - Country:US
Practice Address - Phone:770-421-8094
Practice Address - Fax:770-421-8096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-28
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty