Provider Demographics
NPI:1912965252
Name:MALCOLM M TRAXLER JR MD PC
Entity type:Organization
Organization Name:MALCOLM M TRAXLER JR MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:M
Authorized Official - Last Name:TRAXLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:678-392-5429
Mailing Address - Street 1:102 PILGRIM VILLAGE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-2577
Mailing Address - Country:US
Mailing Address - Phone:678-392-5429
Mailing Address - Fax:678-947-3256
Practice Address - Street 1:102 PILGRIM VILLAGE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2577
Practice Address - Country:US
Practice Address - Phone:678-392-5429
Practice Address - Fax:678-947-3256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA052651207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11SCFQQMedicare PIN
GAGRP7411Medicare ID - Type Unspecified
GAH89456Medicare UPIN