Provider Demographics
NPI:1649516006
Name:DR. THOMAS R FITZSIMMONS MD PC
Entity type:Organization
Organization Name:DR. THOMAS R FITZSIMMONS MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:FITZSIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-997-5347
Mailing Address - Street 1:1215 EAGLES LANDING PARKWAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281
Mailing Address - Country:US
Mailing Address - Phone:770-997-5347
Mailing Address - Fax:678-289-0191
Practice Address - Street 1:1215 EAGLES LANDING PARKWAY
Practice Address - Street 2:SUITE 105
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-997-5347
Practice Address - Fax:678-289-0191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-12
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA056566208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA783252541CMedicaid