Provider Demographics
NPI:1649454265
Name:PRINCETON LAKES INTERNAL MEDICINE
Entity type:Organization
Organization Name:PRINCETON LAKES INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-637-9155
Mailing Address - Street 1:3885 PRINCETON LAKES WAY SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5589
Mailing Address - Country:US
Mailing Address - Phone:404-344-0059
Mailing Address - Fax:404-344-9195
Practice Address - Street 1:3885 PRINCETON LAKES WAY SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5589
Practice Address - Country:US
Practice Address - Phone:404-344-0059
Practice Address - Fax:404-344-9195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1538167119174400000X
GA1689894883174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAH77843Medicare UPIN
GAH45156Medicare UPIN