Basic Information
| Provider Information | |||||||||
| NPI: | 1235284928 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRENADA LAKE INPATIENT MEDICINE ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 52007 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303550007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783970060 | ||||||||
| FaxNumber: | 6783970065 | ||||||||
| Practice Location | |||||||||
| Address1: | 960 J K AVENT DR | ||||||||
| Address2: | |||||||||
| City: | GRENADA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389015230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622277492 | ||||||||
| FaxNumber: | 6622277541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | HEARTSILL | ||||||||
| AuthorizedOfficialFirstName: | KEITH | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6622277172 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.