Provider Demographics
NPI:1174905830
Name:FIDELITY HEALTH CARE GROUP, LLC
Entity type:Organization
Organization Name:FIDELITY HEALTH CARE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:478-290-8509
Mailing Address - Street 1:950 EAGLES LANDING PKWY
Mailing Address - Street 2:# 152
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7343
Mailing Address - Country:US
Mailing Address - Phone:703-929-8967
Mailing Address - Fax:404-601-8328
Practice Address - Street 1:950 EAGLES LANDING PKWY
Practice Address - Street 2:# 152
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7343
Practice Address - Country:US
Practice Address - Phone:703-929-8967
Practice Address - Fax:404-601-8328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038495101YP2500X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1194765420OtherNPI