Basic Information
| Provider Information | |||||||||
| NPI: | 1730194457 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TMC INTERNAL MEDICINE ASSOCIATES VILLA RICA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | VILLA RICA FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7708369261 | ||||||||
| Practice Location | |||||||||
| Address1: | 690 DALLAS HWY | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | VILLA RICA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301801209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704563790 | ||||||||
| FaxNumber: | 7704563785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 06/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | DREILING | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VP | ||||||||
| AuthorizedOfficialTelephone: | 7708388038 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CH5396 | 01 | GA | MEDICARE ID | OTHER |