Provider Demographics
NPI:1295050987
Name:IMMUNE RECOVERY INSTITUTE INC
Entity type:Organization
Organization Name:IMMUNE RECOVERY INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:770-455-6100
Mailing Address - Street 1:4536 CHAMBLEE DUNWOODY RD
Mailing Address - Street 2:STE 250
Mailing Address - City:DUNWOODY
Mailing Address - State:GA
Mailing Address - Zip Code:30338-6200
Mailing Address - Country:US
Mailing Address - Phone:770-455-6100
Mailing Address - Fax:770-455-1999
Practice Address - Street 1:4536 CHAMBLEE DUNWOODY RD
Practice Address - Street 2:STE 250
Practice Address - City:DUNWOODY
Practice Address - State:GA
Practice Address - Zip Code:30338-6200
Practice Address - Country:US
Practice Address - Phone:770-455-6100
Practice Address - Fax:770-455-1999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty