Provider Demographics
NPI:1104100395
Name:NOUVEAU MEDIC LLC
Entity type:Organization
Organization Name:NOUVEAU MEDIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOY
Authorized Official - Middle Name:S
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:NMD, APRN,MPH
Authorized Official - Phone:678-653-0045
Mailing Address - Street 1:600 PHIPPS BLVD NE APT 1304
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-3342
Mailing Address - Country:US
Mailing Address - Phone:678-653-0045
Mailing Address - Fax:404-393-3640
Practice Address - Street 1:600 PHIPPS BLVD NE APT 1304
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-3342
Practice Address - Country:US
Practice Address - Phone:678-653-0045
Practice Address - Fax:404-393-3640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-05
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051126207QA0000X, 207QA0505X
207RI0001X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207RI0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical & Laboratory ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GANAOtherNA