Basic Information
| Provider Information | |||||||||
| NPI: | 1265618946 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEVINE | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | EDEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2230 TOWNE LAKE PKWY | ||||||||
| Address2: | BLDG 300, SUITE 100 | ||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301895540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705924424 | ||||||||
| FaxNumber: | 7705924895 | ||||||||
| Practice Location | |||||||||
| Address1: | 2230 TOWNE LAKE PKWY | ||||||||
| Address2: | BLDG 300, SUITE 100 | ||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301895540 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705924424 | ||||||||
| FaxNumber: | 7705924895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2008 | ||||||||
| LastUpdateDate: | 04/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 1571 | GA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 003186881A | 05 | GA | MEDICAID | 773830693A | 05 | GA | MEDICAID | 003186881B | 05 | GA | MEDICAID | 773830693C | 05 | GA | MEDICAID |