Basic Information
| Provider Information | |||||||||
| NPI: | 1447618707 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONCIERGE MEDICAL MGMT GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 OLD ROSWELL RD STE 117 | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300768685 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007048875 | ||||||||
| FaxNumber: | 8888401265 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 OLD ROSWELL RD STE 117 | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30076 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007048875 | ||||||||
| FaxNumber: | 8888167047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2016 | ||||||||
| LastUpdateDate: | 05/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | BONNER | ||||||||
| AuthorizedOfficialFirstName: | NANCY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6785009568 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Contractor | 332900000X | N | Suppliers | Non-Pharmacy Dispensing Site | 333600000X | Y | Suppliers | Pharmacy |
No ID Information.