Basic Information
| Provider Information | |||||||||
| NPI: | 1235532284 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FASTTRACK IMMEDIATE CARE OF ALBANY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4380 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300234380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8887280882 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2822 NOTTINGHAM WAY | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317077629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2294961193 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2014 | ||||||||
| LastUpdateDate: | 10/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | DERANEY | ||||||||
| AuthorizedOfficialFirstName: | JARED | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8887280882 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | SOLE MEMBER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | GA48063 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.