Provider Demographics
NPI:1265879597
Name:PHYSICAL REHAB MEDICINE SPECIALISTS LLC
Entity type:Organization
Organization Name:PHYSICAL REHAB MEDICINE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PARCHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNALLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-674-4888
Mailing Address - Street 1:PO BOX 678037
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8037
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 FOUNTAIN DR
Practice Address - Street 2:STE D
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-7023
Practice Address - Country:US
Practice Address - Phone:770-674-4888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067000208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty