Basic Information
| Provider Information | |||||||||
| NPI: | 1467066241 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN PHYSICIAN PRACTICE GROUP PC | ||||||||
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| OtherOrganizationName: | TEST4FREE.ORG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3180 N POINT PKWY STE 302 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4048005181 | ||||||||
| FaxNumber: | 4048005797 | ||||||||
| Practice Location | |||||||||
| Address1: | 3180 N POINT PKWY STE 302 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782248686 | ||||||||
| FaxNumber: | 6782248879 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2020 | ||||||||
| LastUpdateDate: | 09/02/2020 | ||||||||
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| AuthorizedOfficialLastName: | BACHAR | ||||||||
| AuthorizedOfficialFirstName: | MOSHE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4048005181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.