Basic Information
| Provider Information | |||||||||
| NPI: | 1649766791 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEACHTREE IMMEDIATE CARE FP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 HIGHWAY 54 W STE 201 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302144538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786889685 | ||||||||
| FaxNumber: | 7706263791 | ||||||||
| Practice Location | |||||||||
| Address1: | 3991 HIGHWAY 78 W STE 100 | ||||||||
| Address2: | |||||||||
| City: | SNELLVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300393929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6787868677 | ||||||||
| FaxNumber: | 6786941787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2018 | ||||||||
| LastUpdateDate: | 07/02/2018 | ||||||||
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| AuthorizedOfficialLastName: | MALIK-ROE | ||||||||
| AuthorizedOfficialFirstName: | ANDREA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6785046392 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2018193062 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.