Basic Information
| Provider Information | |||||||||
| NPI: | 1154859817 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MDVIP MEDICAL GROUP GA-ATL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 HOWELL MILL RD NW STE 525 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303182538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613536344 | ||||||||
| FaxNumber: | 4043508507 | ||||||||
| Practice Location | |||||||||
| Address1: | 1800 HOWELL MILL RD NW STE 525 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303182538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043673070 | ||||||||
| FaxNumber: | 4043673085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2017 | ||||||||
| LastUpdateDate: | 12/09/2020 | ||||||||
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| AuthorizedOfficialLastName: | KLEMES | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5619824300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MDVIP MEDICAL GROUP HOLDINGS, LLC | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | 12/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.