Provider Demographics
NPI:1881419406
Name:DIVINE MERCY MEDICAL GROUP LLC
Entity type:Organization
Organization Name:DIVINE MERCY MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISABELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:VIKUMITSI
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:678-992-6132
Mailing Address - Street 1:1260 HIRAM DAVIS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-6628
Mailing Address - Country:US
Mailing Address - Phone:877-258-6331
Mailing Address - Fax:
Practice Address - Street 1:1260 HIRAM DAVIS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-6628
Practice Address - Country:US
Practice Address - Phone:877-258-6331
Practice Address - Fax:718-362-1651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty