Provider Demographics
NPI:1952539058
Name:METROMED,LLC
Entity Type:Organization
Organization Name:METROMED,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-606-0712
Mailing Address - Street 1:11348 TARA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6277
Mailing Address - Country:US
Mailing Address - Phone:404-933-5894
Mailing Address - Fax:
Practice Address - Street 1:11348 TARA BLVE. STE.100
Practice Address - Street 2:
Practice Address - City:LOVEJOY
Practice Address - State:GA
Practice Address - Zip Code:30228-3558
Practice Address - Country:US
Practice Address - Phone:404-606-0712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-26
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008459261QM1300X, 261QP2300X, 261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA008459Medicaid