Provider Demographics
NPI:1174783435
Name:AG FAMILY MEDICINE, PC
Entity type:Organization
Organization Name:AG FAMILY MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANG SOO
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-614-9799
Mailing Address - Street 1:530 HIGHLAND STATION DR
Mailing Address - Street 2:SUITE 2007
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6571
Mailing Address - Country:US
Mailing Address - Phone:770-614-9799
Mailing Address - Fax:770-614-9789
Practice Address - Street 1:530 HIGHLAND STATION DR
Practice Address - Street 2:SUITE 2007
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6571
Practice Address - Country:US
Practice Address - Phone:770-614-9799
Practice Address - Fax:770-614-9789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59806261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA868452174AMedicaid