Provider Demographics
NPI:1639869860
Name:GA VISITING PROVIDERS, PLLC
Entity type:Organization
Organization Name:GA VISITING PROVIDERS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KASSAB
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:248-763-8266
Mailing Address - Street 1:3212 WINCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2420
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3212 WINCHESTER RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2420
Practice Address - Country:US
Practice Address - Phone:248-763-8266
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty