Basic Information
| Provider Information | |||||||||
| NPI: | 1710058938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BETHESDA FAMILY PRACTICE ASSOC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4039 ATLANTA ST | ||||||||
| Address2: | |||||||||
| City: | POWDER SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301272666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709433139 | ||||||||
| FaxNumber: | 7704395501 | ||||||||
| Practice Location | |||||||||
| Address1: | 4039 ATLANTA ST | ||||||||
| Address2: | |||||||||
| City: | POWDER SPRINGS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301272666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709433139 | ||||||||
| FaxNumber: | 7704395501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | SALTZ | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 7709433139 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 031115 | GA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.