Provider Demographics
NPI:1669414066
Name:MONTREAL INTERNAL MEDICINE ASSOCIATES, PC
Entity type:Organization
Organization Name:MONTREAL INTERNAL MEDICINE ASSOCIATES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIFULCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-938-9761
Mailing Address - Street 1:1462 MONTREAL RD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6929
Mailing Address - Country:US
Mailing Address - Phone:770-938-9761
Mailing Address - Fax:770-938-6509
Practice Address - Street 1:1462 MONTREAL RD
Practice Address - Street 2:SUITE 303
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6929
Practice Address - Country:US
Practice Address - Phone:770-938-9761
Practice Address - Fax:770-938-6509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP2831Medicare UPIN