Basic Information
| Provider Information | |||||||||
| NPI: | 1356602205 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INMED CLINICAL SERVICES LLC | ||||||||
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| OtherOrganizationName: | NORTH SHORE HEALTH CARE ASSOCIATES PRIMARY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5013 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361035013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343860343 | ||||||||
| FaxNumber: | 3343860382 | ||||||||
| Practice Location | |||||||||
| Address1: | 773 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305254257 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067824233 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2012 | ||||||||
| LastUpdateDate: | 06/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENSON | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3343860343 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INMED CLINICAL SERVICES LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.