Provider Demographics
NPI:1386908739
Name:TUCKER INTERNAL MEDICINE, LLC
Entity type:Organization
Organization Name:TUCKER INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-366-1229
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30085-0506
Mailing Address - Country:US
Mailing Address - Phone:770-414-5758
Mailing Address - Fax:770-414-8699
Practice Address - Street 1:4228 FIRST AVE
Practice Address - Street 2:STE 1
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4426
Practice Address - Country:US
Practice Address - Phone:770-414-5758
Practice Address - Fax:770-414-8699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-30
Last Update Date:2012-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028960261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000335838KMedicaid
GA000335838KMedicaid