Provider Demographics
NPI:1932379666
Name:MEDICAL CENTRE
Entity type:Organization
Organization Name:MEDICAL CENTRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:FELTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-922-9222
Mailing Address - Street 1:1815 HIGHWAY 138 SE STE 800
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2098
Mailing Address - Country:US
Mailing Address - Phone:770-922-9222
Mailing Address - Fax:770-922-8794
Practice Address - Street 1:1815 HIGHWAY 138 SE STE 800
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2098
Practice Address - Country:US
Practice Address - Phone:770-922-9222
Practice Address - Fax:770-922-8794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA30996173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA01BDFMTMedicare PIN