Provider Demographics
NPI:1982474151
Name:PEACHTREE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:PEACHTREE MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BRILLIANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:470-300-2019
Mailing Address - Street 1:13010 MORRIS RD STE 650
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-5197
Mailing Address - Country:US
Mailing Address - Phone:470-300-2019
Mailing Address - Fax:
Practice Address - Street 1:13010 MORRIS RD
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-3873
Practice Address - Country:US
Practice Address - Phone:470-300-2019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service