Provider Demographics
NPI:1316278948
Name:EVANS MILL FAMILY PRACTICE
Entity type:Organization
Organization Name:EVANS MILL FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PURUSHOTTAM
Authorized Official - Middle Name:KUMAR
Authorized Official - Last Name:GARG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-995-8811
Mailing Address - Street 1:2724 EVANS MILL RD
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-7417
Mailing Address - Country:US
Mailing Address - Phone:770-484-7172
Mailing Address - Fax:
Practice Address - Street 1:2724 EVANS MILL RD
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-7417
Practice Address - Country:US
Practice Address - Phone:770-484-7172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA63421261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service