Basic Information
| Provider Information | |||||||||
| NPI: | 1861803371 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AFC PHYSICIANS OF GEORGIA, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3700 CAHABA BEACH RD | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352425225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2054038902 | ||||||||
| FaxNumber: | 2054212109 | ||||||||
| Practice Location | |||||||||
| Address1: | 1095 WOODSTOCK RD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300750000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6783472464 | ||||||||
| FaxNumber: | 6783472460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2014 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHANSEN | ||||||||
| AuthorizedOfficialFirstName: | RANDY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2054212101 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AFC PHYSICIANS OF GEORGIA, PC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 202G708342 | 01 | GA | MEDICARE GROUP PTAN# | OTHER |