Basic Information
| Provider Information | |||||||||
| NPI: | 1639314057 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHC MEDICAL PARTNERS OF GEORGIA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12201 BLUEGRASS PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402992361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025687364 | ||||||||
| FaxNumber: | 5025687136 | ||||||||
| Practice Location | |||||||||
| Address1: | 54 PEACHTREE PARK DR NE | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043516041 | ||||||||
| FaxNumber: | 4043551092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2008 | ||||||||
| LastUpdateDate: | 07/15/2016 | ||||||||
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| AuthorizedOfficialLastName: | LOGAN | ||||||||
| AuthorizedOfficialFirstName: | PENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5025582193 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SHC MEDICAL PARTNERS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 535401780A | 05 | GA | MEDICAID |