Basic Information
| Provider Information | |||||||||
| NPI: | 1982679684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCHANAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 742616 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303742616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702198420 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3575 BRASELTON HWY | ||||||||
| Address2: | |||||||||
| City: | DACULA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300191155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708485300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 02/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 054557 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 08CBBNC | 01 | GA | MEDICARE PIN THE BRASELTON CLINIC | OTHER | 444911088N | 05 | GA | MEDICAID | 444911088S | 05 | GA | MEDICAID | 08CBCHP | 01 | GA | MEDICARE PIN QUICK CARE | OTHER | 444911088P | 05 | GA | MEDICAID | 444911088L | 05 | GA | MEDICAID | 444911088Q | 05 | GA | MEDICAID | 511I080027 | 01 | GA | MEDICARE PIN ADVANTAGE SPORTS MEDICINE | OTHER |