Basic Information
| Provider Information | |||||||||
| NPI: | 1508459199 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID ATLANTIC MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 746004 | ||||||||
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| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303746004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4849137434 | ||||||||
| FaxNumber: | 4849137587 | ||||||||
| Practice Location | |||||||||
| Address1: | 2228 MARTIN LUTHER KING JR AVE SE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200205700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2029644727 | ||||||||
| FaxNumber: | 2029022238 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2021 | ||||||||
| LastUpdateDate: | 04/12/2021 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP IPM | ||||||||
| AuthorizedOfficialTelephone: | 6107683300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.