Basic Information
| Provider Information | |||||||||
| NPI: | 1912956046 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIEDMONT MEDICAL CARE CORPORATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102321 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708012500 | ||||||||
| FaxNumber: | 7708032121 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 N HIGHLAND AVE NE STE F | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303075625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046589840 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| AuthorizedOfficialLastName: | AQUINO | ||||||||
| AuthorizedOfficialFirstName: | CHRISTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4702713424 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 300030651Y | 05 | GA | MEDICAID |