Provider Demographics
NPI:1194405373
Name:PHYSICIAN 360, INC
Entity type:Organization
Organization Name:PHYSICIAN 360, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CHIEF CLINICAL OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:502-417-7386
Mailing Address - Street 1:3379 PEACHTREE RD NE STE 700
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30326-1419
Mailing Address - Country:US
Mailing Address - Phone:360-861-6199
Mailing Address - Fax:360-282-0136
Practice Address - Street 1:3379 PEACHTREE RD NE STE 700
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-1419
Practice Address - Country:US
Practice Address - Phone:360-861-6199
Practice Address - Fax:360-282-0136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-21
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty