Provider Demographics
NPI:1861781320
Name:HILLANDALE INTERNAL MEDICINE, PC
Entity type:Organization
Organization Name:HILLANDALE INTERNAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WALLACE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-987-8400
Mailing Address - Street 1:5900 HILLANDALE DR
Mailing Address - Street 2:ANNEX E
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-3802
Mailing Address - Country:US
Mailing Address - Phone:770-987-8400
Mailing Address - Fax:770-987-8494
Practice Address - Street 1:5900 HILLANDALE DR
Practice Address - Street 2:ANNEX E
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-3802
Practice Address - Country:US
Practice Address - Phone:770-987-8400
Practice Address - Fax:770-987-8494
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041109207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00687893GMedicaid
11BDTHFMedicare PIN
GAG21584Medicare UPIN