Provider Demographics
NPI:1326218942
Name:ACWORTH IMMEDIATE CARE LLC
Entity type:Organization
Organization Name:ACWORTH IMMEDIATE CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-5135
Mailing Address - Street 1:4450 CALIBRE CROSSING
Mailing Address - Street 2:SUITE 1104
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101
Mailing Address - Country:US
Mailing Address - Phone:770-975-6540
Mailing Address - Fax:770-975-6541
Practice Address - Street 1:4450 CALIBRE CROSSING
Practice Address - Street 2:SUITE 1104
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101
Practice Address - Country:US
Practice Address - Phone:770-975-6540
Practice Address - Fax:770-975-6541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA842071171AMedicaid
GA52230468001OtherBCBS OF GA