Provider Demographics
NPI:1366795973
Name:MERIDIAN INTERNAL MEDICINE AND PRIMARY CARE INC
Entity type:Organization
Organization Name:MERIDIAN INTERNAL MEDICINE AND PRIMARY CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MGR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAY
Authorized Official - Middle Name:OLUKAYODE
Authorized Official - Last Name:OSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-485-5705
Mailing Address - Street 1:1029 N PEACHTREE PKWY STE 376
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-4210
Mailing Address - Country:US
Mailing Address - Phone:404-691-6688
Mailing Address - Fax:
Practice Address - Street 1:3890 REDWINE RD SW STE 210
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5583
Practice Address - Country:US
Practice Address - Phone:404-691-6688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-19
Last Update Date:2012-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044049207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
11BDWFTMedicare PIN
GAG68297Medicare UPIN