Basic Information
| Provider Information | |||||||||
| NPI: | 1407293905 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONCIERGE MEDICINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4720 NELSON BROGDON BLVD | ||||||||
| Address2: | |||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305183480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709451990 | ||||||||
| FaxNumber: | 7709453631 | ||||||||
| Practice Location | |||||||||
| Address1: | 4720 NELSON BROGDON BLVD | ||||||||
| Address2: | |||||||||
| City: | BUFORD | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305183480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709451990 | ||||||||
| FaxNumber: | 7709453631 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2013 | ||||||||
| LastUpdateDate: | 05/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | DAMBACH | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 7709451990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.