Basic Information
| Provider Information | |||||||||
| NPI: | 1811924251 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TMC INFECTIOUS DISEASES OF WEST GEORGIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR | ||||||||
| Address2: | AUITE 202 | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369250 | ||||||||
| FaxNumber: | 7708369261 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 DIXIE ST | ||||||||
| Address2: | C/O ICU | ||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708369666 | ||||||||
| FaxNumber: | 7708388922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | MACALUSO PEARE | ||||||||
| AuthorizedOfficialFirstName: | DEBBI | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCIAL OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7708388554 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | DG2920 | 01 | GA | MEDICARE ID | OTHER |