Provider Demographics
NPI:1104064815
Name:VISTAS MEDICAL CENTER,PC
Entity type:Organization
Organization Name:VISTAS MEDICAL CENTER,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/CEO
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:KEMDI
Authorized Official - Last Name:IHENACHO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-296-7695
Mailing Address - Street 1:PO BOX 870828
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-0027
Mailing Address - Country:US
Mailing Address - Phone:404-296-7695
Mailing Address - Fax:404-296-7696
Practice Address - Street 1:5329 MEMORIAL DR STE A
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GEORGIA
Practice Address - Zip Code:30083
Practice Address - Country:UM
Practice Address - Phone:404-296-7695
Practice Address - Fax:404-296-7696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA038149261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000727108DMedicaid
GA321313OtherWELLCARE
GA000727108DMedicaid