Provider Demographics
NPI:1982095360
Name:MODERN INTERNAL MEDICINE
Entity type:Organization
Organization Name:MODERN INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-368-8655
Mailing Address - Street 1:2457 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:SUITE A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-1712
Mailing Address - Country:US
Mailing Address - Phone:404-368-8655
Mailing Address - Fax:
Practice Address - Street 1:2457 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:SUITE A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-1712
Practice Address - Country:US
Practice Address - Phone:404-368-8655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty