Provider Demographics
NPI:1457521940
Name:STANFORD MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:STANFORD MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUNCO PATINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-837-1175
Mailing Address - Street 1:142 MITCHELL ST SW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3439
Mailing Address - Country:US
Mailing Address - Phone:404-584-2105
Mailing Address - Fax:404-584-2106
Practice Address - Street 1:142 MITCHELL ST SW
Practice Address - Street 2:SUITE 200
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3439
Practice Address - Country:US
Practice Address - Phone:404-584-2105
Practice Address - Fax:404-584-2106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700407Medicare PIN