Provider Demographics
NPI:1720272412
Name:JOHNS CREEK FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:JOHNS CREEK FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-474-0040
Mailing Address - Street 1:4365 JOHNS CREEK PKWY
Mailing Address - Street 2:SUITE 430
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6089
Mailing Address - Country:US
Mailing Address - Phone:678-474-0040
Mailing Address - Fax:678-474-0095
Practice Address - Street 1:4365 JOHNS CREEK PKWY
Practice Address - Street 2:SUITE 430
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6089
Practice Address - Country:US
Practice Address - Phone:678-474-0040
Practice Address - Fax:678-474-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046525207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB1574OtherRAILROAD MEDICARE GROUP
GRP4691OtherMEDICARE GROUP NUMBER
GA000971308AMedicaid
GRP4691Medicare PIN
DB1574OtherRAILROAD MEDICARE GROUP
H52203Medicare UPIN