Provider Demographics
NPI:1124066261
Name:NORTHLAKE MULTISPECIALTY ASSOCIATES LLC
Entity type:Organization
Organization Name:NORTHLAKE MULTISPECIALTY ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:CHUCK
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-7604
Mailing Address - Street 1:1459 MONTREAL RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-6900
Mailing Address - Country:US
Mailing Address - Phone:770-908-4444
Mailing Address - Fax:770-908-4400
Practice Address - Street 1:1459 MONTREAL RD
Practice Address - Street 2:SUITE 304
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6900
Practice Address - Country:US
Practice Address - Phone:770-908-4444
Practice Address - Fax:770-908-4400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7633Medicare PIN