Basic Information
| Provider Information | |||||||||
| NPI: | 1053405704 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NW GEORGIA FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2513 SHALLOWFORD RD | ||||||||
| Address2: | BUILDING 100 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300666809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705163500 | ||||||||
| FaxNumber: | 7705163660 | ||||||||
| Practice Location | |||||||||
| Address1: | 2526 SHALLOWFORD ROAD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705163500 | ||||||||
| FaxNumber: | 7705163660 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 03/17/2008 | ||||||||
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| AuthorizedOfficialLastName: | ZACHERY | ||||||||
| AuthorizedOfficialFirstName: | TAMIKO | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7705163500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.