Provider Demographics
NPI:1982619789
Name:METRO MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:METRO MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAMILLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-777-0750
Mailing Address - Street 1:11379 SOUTHBRIDGE PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-4469
Mailing Address - Country:US
Mailing Address - Phone:770-777-0750
Mailing Address - Fax:770-777-0521
Practice Address - Street 1:11379 SOUTHBRIDGE PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-4469
Practice Address - Country:US
Practice Address - Phone:770-777-0750
Practice Address - Fax:770-777-0521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054164207Q00000X
GA042386207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP8020Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER