Provider Demographics
NPI:1104972298
Name:CUMMING FAMILY PRACTICE
Entity type:Organization
Organization Name:CUMMING FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-886-8152
Mailing Address - Street 1:319 CANTON RD
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2213
Mailing Address - Country:US
Mailing Address - Phone:770-886-8152
Mailing Address - Fax:770-886-8153
Practice Address - Street 1:319 CANTON RD
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2213
Practice Address - Country:US
Practice Address - Phone:770-886-8152
Practice Address - Fax:770-886-8153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011753207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty