Basic Information
| Provider Information | |||||||||
| NPI: | 1932625548 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LPP OF GEORGIA LLC | ||||||||
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| OtherOrganizationName: | RIVERDALE EMERGENCY PHYSICIANS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5214 MARYLAND WAY STE 404 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6156157605 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11 UPPER RIVERDALE RD SW | ||||||||
| Address2: | |||||||||
| City: | RIVERDALE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302742615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7709918000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2017 | ||||||||
| LastUpdateDate: | 08/16/2017 | ||||||||
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| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6155546885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LEGACY PHYSICIAN PARTNERS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.