Provider Demographics
NPI:1962621532
Name:MID PROVIDER INC
Entity type:Organization
Organization Name:MID PROVIDER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:NORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:GNP
Authorized Official - Phone:404-229-0274
Mailing Address - Street 1:1230 WORTHINGTON HILLS DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1753
Mailing Address - Country:US
Mailing Address - Phone:404-229-0274
Mailing Address - Fax:770-518-4026
Practice Address - Street 1:1230 WORTHINGTON HILLS DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1753
Practice Address - Country:US
Practice Address - Phone:404-229-0274
Practice Address - Fax:770-518-4026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN133089363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADD4864OtherRAILROAD RETIERMENT
GADD4864OtherRAILROAD RETIERMENT