Provider Demographics
NPI:1194768929
Name:PARKWAY PHYSICIANS PRACTICE COMPANY
Entity type:Organization
Organization Name:PARKWAY PHYSICIANS PRACTICE COMPANY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-732-7987
Mailing Address - Street 1:8954 HOSPITAL DR
Mailing Address - Street 2:SUITE 120-A
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2272
Mailing Address - Country:US
Mailing Address - Phone:770-732-7987
Mailing Address - Fax:
Practice Address - Street 1:8954 HOSPITAL DR
Practice Address - Street 2:SUITE 120-A
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2272
Practice Address - Country:US
Practice Address - Phone:770-732-7987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACG7003Medicare ID - Type UnspecifiedRAILROAD MEDICARE
GAGRP2567Medicare ID - Type UnspecifiedCAHABA MEDICARE/ GA MEDIC