Provider Demographics
NPI:1952599516
Name:SOUTH FORSYTH FAMILY MEDICINE AND PEDIATRICS LLC
Entity Type:Organization
Organization Name:SOUTH FORSYTH FAMILY MEDICINE AND PEDIATRICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLING & INSURANCE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DINA
Authorized Official - Middle Name:J
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-343-9112
Mailing Address - Street 1:1845 LOCKEWAY DR
Mailing Address - Street 2:SUITE 404
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-5936
Mailing Address - Country:US
Mailing Address - Phone:770-343-9112
Mailing Address - Fax:770-343-8911
Practice Address - Street 1:1845 LOCKEWAY DR
Practice Address - Street 2:SUITE 404
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-5936
Practice Address - Country:US
Practice Address - Phone:770-343-9112
Practice Address - Fax:770-343-8911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2401782207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000630759EMedicaid
GA000630759FMedicaid
GA000630759FMedicaid