| South Forsyth Family Medicine And Pediatrics Llc | |
|
1845 Lockeway Dr Suite 404 Alpharetta GA 30004-5936 | |
| (770) 343-9112 | |
| (770) 343-8911 |
| Full Name | South Forsyth Family Medicine And Pediatrics Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 1845 Lockeway Dr, Alpharetta, Georgia |
| Authorized Official Name and Position | Dina J Gore (MEDICAL BILLING & INSURANCE MANAGER) |
| Authorized Official Contact | 7703439112 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| South Forsyth Family Medicine And Pediatrics Llc 1845 Lockeway Dr Suite 404 Alpharetta GA 30004-5936 Ph: (770) 343-9112 | South Forsyth Family Medicine And Pediatrics Llc 1845 Lockeway Dr Suite 404 Alpharetta GA 30004-5936 Ph: (770) 343-9112 |
| NPI Number | 1952599516 |
|---|---|
| Provider Enumeration Date | 10/09/2007 |
| Last Update Date | 01/17/2013 |
| Medicare PECOS PAC ID | 6901864255 |
|---|---|
| Medicare Enrollment ID | O20050103000747 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1952599516 | NPI | - | NPPES |
| 000630759E | Medicaid | GA | |
| 000630759F | Medicaid | GA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 2401782 (Georgia) | Primary |
| 208000000X | Pediatrics | 2401782 (Georgia) | Secondary |
| Provider Name | Mark Glodener |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1174629885 PECOS PAC ID: 3779541024 Enrollment ID: I20050104000597 |
| Provider Name | David Boaz |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1750305124 PECOS PAC ID: 0042278392 Enrollment ID: I20050105000233 |
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