Provider Demographics
NPI:1972636710
Name:NORTHEAST INTERNAL MEDICINE, P.C.
Entity type:Organization
Organization Name:NORTHEAST INTERNAL MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIGAMON-BELTRAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-267-9484
Mailing Address - Street 1:333 ALCOVY ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2180
Mailing Address - Country:US
Mailing Address - Phone:770-267-9484
Mailing Address - Fax:770-267-1600
Practice Address - Street 1:333 ALCOVY ST
Practice Address - Street 2:SUITE 8
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2180
Practice Address - Country:US
Practice Address - Phone:770-267-9484
Practice Address - Fax:770-267-1600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA065514207RI0200X, 207R00000X
GA027031207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003124228AMedicaid
GA3692OtherGRP PTAN
GA027031OtherLICENSE NUMBER
GA1639254881OtherNPI
GA202I118301OtherPTAN
GA000299912AMedicaid
GA1912194960OtherNPI
GA065514OtherLICENSE NUMBER