Provider Demographics
NPI:1215136890
Name:SYNERGY MEDICAL CENTERS OF ROSWELL, LLC
Entity type:Organization
Organization Name:SYNERGY MEDICAL CENTERS OF ROSWELL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:FALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-581-2191
Mailing Address - Street 1:1065 BRIDGE MILL AVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-7717
Mailing Address - Country:US
Mailing Address - Phone:770-581-2191
Mailing Address - Fax:770-704-1884
Practice Address - Street 1:5499 JONESBORO RD
Practice Address - Street 2:SUITE 240
Practice Address - City:LAKE CITY
Practice Address - State:GA
Practice Address - Zip Code:30260-3553
Practice Address - Country:US
Practice Address - Phone:770-881-2191
Practice Address - Fax:770-704-1884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-13
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008003111N00000X
GA56072174400000X
GAPT006876174400000X
GA22393207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP8149Medicare PIN
6343330001Medicare NSC